Torture Deck Flashcards
(982 cards)
1
Q
Young woman - failed mtx, switch to what regimen?
A
Pulsed Act D (THIS ONE), EMACO
2
Q
XRT vs brachy - which sx is shared
A
Fatigue (THIS ONE), vaginal stenosis, 2 other choices
3
Q
Wrist drop
A
Radial nerve palsy (C5-T1)
4
Q
Why is PEEP important for tx of ARDS
A
Reduces FiO2 requirement with recruitment of alveoli
5
Q
WHO score - what has greatest impact: the one worth 4 points
A
10^4-5, pregnancy, interval months from index pregnancy > 12 months (THIS ONE), GI met
6
Q
Which pressor not use in sepsis
A
“Dobutamine - not a pressor but an inotrope, b/c associated with hypotension, usually used for cardiogenic failure Most commonly used - norepi, epi”
7
Q
Which population of pts did not need MRI for screening along with mammogram ( the top 6 are reasons to get mRI, i think bottom list is reasons NOT TO the last line i added is for sure a reason NOT TO per ACS)
A
“ACS (American Cancer Society) based on evidence: these are all reasons TO GET BOTH 1. BRCA 2. First degree relative of BRCA carrier, but person is untested 3. Lifetime risk 20-25% or more based on BRCAPRO or other fam hx model ACS based on expert opinion 4. Radiation to chest between 10-30 years 5. Li-Fraumeni syndrome and first deg relatives 6. Cowden and Bannayan-Riley-Ruvalcaba syndromes and first deg relatives No: Lifetime risk 15-20%, LCIS or ALH, ADH, dense breasts, personal hx of breast cancer including DCiS, <15% risk (The ACS does not recommend the use of breast MRI in women who have a less than 15% lifetime risk of breast cancer)”
8
Q
Which pathway is TNF-beta part of
A
Extrinsic pathway of apoptosis
9
Q
Which opioid has the longest half life
A
Methadone
10
Q
Which of the following is least likely to be associated with BRCA2
A
small bowel Biliary, GU, breast, ovarian, colon (this one) this was hard to find but i think its colon
11
Q
Which is not in a proliferation pathway?
A
BAX (apoptosis gene)
12
Q
“Which is not associated with breast cancer? A. Li Fraumeni B. MEN2 C. Cowden D. axial telangiectasia syndrome (aka hereditary hemorrhagic telangiectasia aka Osler-Weber-Rendu syndrome)”
A
B. MEN2 (multiple endocrine neoplasia)
13
Q
Which is not a GF treatment targeted
A
“EGFR, VEGF, MTOR (THIS ONE) so everolimus (aka affinitor) binds to FK binding protein to modulate activity of mTOR mtor inhibits IL-2 mediated signal transduction, results in cell cycle arrest in G1-S”
14
Q
“Which is not a gap acidosis Mnemonic for anion gap metabolic acidosis”
A
“RTA (and diarrhea) and pancreatic leak MUDPILES methanol uric acid (aka uremia/ARF) DKA paraldehyade, phenformin iron, INH lactic acidosis ethylene glycol salicylates”
15
Q
Which is not a branch of the femoral artery
A
“Deep circumflex (this one) Actual branches: superficial epigastric, superficial iliac circumflex, superficial external pudendal, deep ext pudendal, deep femoral, ends as the popliteral artery”
16
Q
Which is most likely to cause non-gap acidosis
A
Renal failure, pancreatic leak (this one), salicylic acid, rhabdo, DKA
17
Q
Which is most likely to be a factor in oxygen enhancement ratio
A
“Tx of groins in vulvar ca, adjuvant tx to Pa nodes, 6 cm cervical mass (this one) Necrotic (less oxygenated) cells are more radioresistant, on the neighborhood of 2-3x”
18
Q
Which is least attributed to OSA
A
longer hospital stay, MI, stroke, cardiac arrythmia (THESE ALL ARE!) i cant find the answer
19
Q
Which is least affected — wtf
A
Blunting of villi, hypophosphatemia, selinium deficiency (THIS ONE)
20
Q
Which is a direct (rather than indirect) effect of radiation
A
Photons, gamma rays, hypoxia, LET (this one), chemosens
21
Q
Which has the least ionotropy?
A
Phenylephrine
22
Q
Which gene is not breast cancer risk related?
A
APC (this one, familial adenomatous polyposis), PTEN, p53
23
Q
Which factor leads to poor outcome in treatment of ovca with Her2neu
A
“No amplication of ERB2 (THIS ONE), mutaiton of ERB2, mutation of ERB1, amplication of ERB1 amplification/overexpression of ERBB2 gene occurs in ovarian cancer, assoc with worse prognosis Her2 (trastuzumab or herceptin)”
24
Q
Which drug is a vesicant
A
“Vinca List of ones I care about from uptodate: A D M V Y (actD, doxorubicin, mitomycin, vinca, yondelis or trabectedin)”
25
Which drug increases platelets
IL-11 (THIS ONE)- actually used for ppx against thrombocytopenia!, bactrim, vanco, GCSF, heparin - the others all may lower
26
Which chemo not active in S phase
Taxol (this one), anthracyclines
27
Which chemo leads to ammenorrhea in young woman
"vincristine, etoposide, mtx, cisplatin (answer - other choice, non EMACO?? vs. I chose the only one that was non cell cycle specific - cis) NON CELL CYCLE SPECIFIC ARE MORE LIKELY TO BE TOXIC"
28
Which chemo don't have to renally dose
"Cytoxan (this one- def no), topo (def yes), gem (time if on HRD), methotrexate (def yes) A BICC THEM (ones to renally dose) Act D, bleo, ifos, cis/carbo, cytoxan, topotecan, hydroxyurea, etoposide, mtx/pemetrexed"
29
Which chemo are pro-drugs
Capecitabine, cyclophosphamide, ifosfamide, gemcitabine
30
Which agent is cell cycle specific
"mtx, taxol, cisplatin, carboplatin, cyclophosphamide (mtx vs. taxol??) Cell cycle specific Inhibition of DNA synthesis/repair (S phase): anti-folates (i.e., mtx, pemetrexed), nucleoside analogues (5-FU, gemcitabine), anthracyclines (act D) and etoposide stabilize DNA topoisomerase II cleavable complex); topocean which stabilizes DNA-topoisomerase I cleavable complex Inhibition of M phase: taxanes which promote tubulin polymeraizatio, vinca alkaloids which inhibit tubulin polymerization (vincristine) Not cell cycle specific: Alkylating compounds (G1,G2,S): direct DNA damage, DNA adduct formation, free radical production; i.e., radiation, platinum, bleomycin; cyclophosphamide Doxorubin: most active in S but not phase specific"
31
Where does the SMV drain
Portal v
32
Where does the IMV drain
Splenic v to portal v
33
Where does superficial epigastric come fron
Femoral
34
Where does internal pudendal come from
Ant division of internal iliac
35
Where does external pudendal come from
Femoral artery
36
Where does deep/inferior epigastric come from
External iliac, which then becomes femoral after
37
Where do growth factors act
Cytosol, nucleus, extracellular (this one) - extracellular signaling between cells
38
Where are progestone receptors located
Nucleus
39
Where are estrogen receptors located
Transmembrane initially (once activated by estrogen, can move into nucleus)
40
when would you use a one tailed versus a two tailed
When the alternative hypothesis only goes in one direction (rather than two)
41
When would you use 21 gene RT-PCR (aka oncotype Dx)
"if ER neg, Her2neu neg, node pos if er pos, Her2neur pos, if er neg, Her2neu pos if ER pos Her2neu neg, LN pos early-stage invasive breast cancer with ER+, Her2- cancers, node neg / from their website to decide if add chemo to hormonal therapy"
42
When is bev held
"Proteinusria >/- 2g in 24h urine Nephrotic syndrome cutoff is 3.5 g/day (or hypertensive crisis > 180/120 or hypertensive encephalopathy)"
43
What would adding TVUS do to elevated CA-125 screening value
Incr sens (this one), decr spec, decr sens
44
What were interferons originally thought to do
Inhibit viral infection or "interfering with viral machinery"
45
What variable not used for power calculation
Actual means for groups, expected diff, significant level, power, chi square value (this one)
46
"What toxicity does mtx not have What ""rescue"" med is available"
"Cardiotoxicity (THIS ONE), hepatotoxicity, nephrotoxocity, hematologic Leucovorin - derivative of folic acid (to overcome high dose mtx BM toxicity Substitute for endogenous reduced-folate cofactor ThF that is Decreased by mtx, ""rescues"" cells by replenishing intracellular reduced folate pools and preventing mtx toxicity via blockade of thymidine synthesis (give within 48 hours of mtx) FYI can also be used to potentiate anti-tumor activity of 5-FU"
47
What to do if recognized pancreatic injury during debulk
Repair injury, pancreatectomy (this one if option is distal?), splenectomy, place pelvic drain (place near site?)
48
What to do if on vent and low PaO2
Increase FiO2, increase PEEP
49
What to do if on vent and hypercapnea
Increase TV and RR
50
What rad/xrt is used to treat superficial lesions (aka skin)
Electrons (this one), gamma ray, orthovoltage
51
What preop abx is most assciated with cdiff
"From uptodate: clindamycin, floxacin, cephalosporins, PCN Options cefotetan (this one), ertapenem, two other choices"
52
What part of her2 is the target of intervention
Extracellular portion
53
What nerve injury with foot drop
Common peroneal nerve (from the sciatic nerve)
54
What medical belief is aligned pt wanting to do 5th line chemo after bowel obstruction
Autonomy (this one) nonmalificience, beneficience
55
What med to give someone with normal wedge pressure and hypotension
Since normal wedge pressure pump is ok, need increase SVR --> use neosynephrine (phenylephrine)
56
What lymph nodes drain below the pectineate line
Inguinal LN
57
What is the other name for the protein CA125
MUC16 or mucin16
58
What is the most common side effect of amifostine
"Hypotension (62%); can protect the kidneys from cisplatin (also neuropathy) and BM from cisplatin an cyclophosphamide, protects slaivary glands during radiation tx"
59
"What is the least likely complication associated with extensive terminal ileum resection? blind loop syndrome - small bowel bacterial overgrowth A. intrinsic factor deficiency B. Vit B12 def C. Vit K def D. fat malabsorption E. iron"
"intrinsic factor deficiency - made in gastric cells, so plenty in system; B12 just not absorbed if resection >100 cm, bile acid deficiency b/c bile acid losses exceed compensatory increase in hepatic bile acid production this exacerbates absorption of fat and fat-soluble vitamins disruption of fluid absorption so cannot tolerate large bolus feedings or high osmolarity (i.e., simple carbs) fat soluble vitamins (vitamin A,D,E,K)"
60
"What is the least likely cancer in a pregnant patient with no history of malignancy a. lymphoma b. melanoma c. thyroid d. colon e. breast"
"d. colon most common (Salani et al) breast cancer, cvx cancer, lymphoma, ov cancer, melanoma, thyroid slightly more common than colon"
61
"What is the LEAST appropriate palliative intervention in a woman with a 12 cm cecum and malignant sigmoid lesion? A. pain management with tincture of opium b. loop colostomy c. gastric tube d. tube through the cecum e. colorectal stent"
Gastric tube (too proximal)
62
What is the function of iressa? (generic: gefitinib)
acts against EGFR mutations ( EGFR inhibitor)
63
What is the elemental source for brachytherapy/interstitial
Iridium (this one), cesium
64
What is the dose limiting toxicity of irinotecan?
"Diarrhea Occuring during infusion- responsive to atropine (anti-cholinergic) Occuring subacute 2-3 weeks after is not responsive to that, so use anti-motility Can be life-threatening"
65
What is the depth of dose for 12 MeV in radiation
4 cm (R90 where beyond <90% of dose is administered)
66
What is the definition of linear energy transder (LET)?
"The rate of deposition of energy along the path of the radiation beam Amount of energy transferred to local environment in form of ionizations and excitations Average energy for a given path length traveled Average path length for a given deposited energy Unit = kEV/um"
67
What is the cause of refractory hypokalemia in setting of K replacement
"Bicarb, hypomag (this one), phosphorus, calcium Patients with hypokalemia may also have hypomagnesemia due to concurrent loss with diarrhea or diuretic therapy or, in patients with hypomagnesemia as the primary abnormality, renal potassium wasting [21,22]. Such patients can be refractory to potassium replacement alone [23]. Thus, measurement of serum magnesium should be considered in patients with hypokalemia and, if present, hypomagnesemia should be treated. - uptodate"
68
What is the advantage of protons over electrons in radiation
"Dose stops at precise place due to Bragg peak (electrons are less precise; most of the dose is delivered 0.5-3 cm from patient's skin and then gradually loses energy until reaches its target; affectingn the non-target tissues)"
69
What is most predictive of LN mets in pt with 3cm vulvar cancer 1 cm from midline
Depth of invasion, contralateral LN pos (this one), tumor size, LVSI
70
What is methylation
"epigenetic change (methylation of cytosine residues residing next to guanine residues CpG dinucleotides, methylation silences gene expression) not a SNP"
71
What is measure of intraobserve variability
Kappa
72
What is major reason to heat blood when tranfusing during major intraop blood los
"Viscosity, impact on plt (this one), other Hypothemia decreases enzymatic activity of clotting factors and reduces # and fn of platelets"
73
"What is least associated with ACOG colonoscopy recs A. colonoscopy q10yr B. FOBT self collected q year C. FOBT collected by physician q year D. double contrast barium enema q5 yrs"
D. double contrast barium enema
74
"What is high LET radiation? 1. neutrons 2. protons 3. photons 4. Gamma rays "
"High LET = alpha, neutrons Low LET = electrons, gamma rays and x-rays (both electromagnetic radiation)"
75
What is better 6 month long term LSC vs. LAP endom ca staging
LSC - physical function, QOL, scar, pain
76
What is associated with worse IP chcemo administration
"smaller mol weight (for ideal IP: large molecular weight size, high conc in preitoneum, no need for liver activation, high volume) low vol increases clearance which is bad)"
77
What is associated with increasing opiate dose
Tolerance associated with increasing dose (THIS ONE), dependance, 2 other choices
78
What is % dose of XRT 1 cm vs 2 cm from source?
400%; b/c dose ~ 1/r squared
79
What has been associated with decreased infection in groin dissection?
Saphenous v. sparing
80
What happens with TP53 mutation
Bind to WT and inactivate, directly impair DNA (this one?), (p53 activate s DNA repair proteins after DNA damage, arrest at G1/S after DNA damage, can initiate apoptosis)
81
What gives off the right gastroepiploic artery
Gastroduodenal artery
82
What factors are important for power calculation
Effect size, sample size
83
What drug is PPE associated with?
Doxil (not a choice); Xeloda aka capecitabine (15-20%)
84
What does ROC curve measure?
"Optimal is upper left corner where false positive rate is 0 and true positive rate is 1 Diagonal through the center represents ""random"" so if above it, ""better than random"" x-axis = False positive rate (or 1-specificity) and y-axis = True positive rate (or sensitivity) (ROC) curve the true positive rate (Sensitivity) is plotted in function of the false positive rate (100-Specificity) for different cut-off points. Each point on the ROC curve represents a sensitivity/specificity pair corresponding to a particular decision threshold. A test with perfect discrimination (no overlap in the two distributions) has a ROC curve that passes through the upper left corner (100% sensitivity, 100% specificity). Therefore the closer the ROC curve is to the upper left corner, the higher the overall accuracy of the test "
85
What does not interact with imatinib
"EGFR (this one), do interact: ckit, ABL, PDGFR from pubchem.ncbi: imatinib inhibits Bcr-Abl fusion protein tyrosine kinase (produced by CML cells that contain Philadelphia chromosome) also inhibits receptor tyrosine kinases for platelet derived growth factor (PDGF) and stem cell factor (SCF)/c-kit tyrosin kinase which is activated in GIST tumors; inhibits proliferation and induces apoptosis in cells that overexpress these oncoproteins"
86
What does more PEEP due to cardiac output
decreases cardiac output (reduces right heart filling and thus decreased stroke volume); decreases PCWP
87
What distinguishes PSTT from choriocarcinoma
INTERMEDIATE trophoblasts, HPL and lower hCG
88
What distinguishes endometrial stromal nodule from low grade ESS
mitosis, atypia, spiral arterioles, LVSI (THIS ONE)
89
What chemo most asscoiated with constipation
Vincristine
90
What chemo is primarily renally cleared
Bleomycin
91
What chemo causes polymeraization of tubulins
Taxol
92
What chemo cannot be given IP
Cyclophosphamide (or any of the prodrugs that require activation in the liver!)
93
What cancer type has the least acute effects?
Ovary, vagina (THIS ONE), bladder, small intestine
94
What artery is transected with en bloc rectosigmoid resection
Superior rectal a (this one), inferior rectal a, marginal a of Drummund
95
What are the parameters for carbo calculator
Age, CrCl (height), gender, weight, AUC
96
What are G coupled receptors
7 membrane spanning proteins that are activated with GTP then self hydrolyze to GDP and turn off
97
What abx is not renally cleared
Flagyl
98
Vulvar cancer: 1 cm vulvar cancer, 2 pos LN in right groin, what is postop adj mgmt?
Bilateral groin XRT, groin + pelvic XRT (this one), other choices
99
Vulvar cancer staging: 2 questions - one that was vulvar lesion with 2 6mm LN pos and other with 2 LN pos with extracapsular spread
IIIB, IIIC - extracapsular spread
100
Vessels encountered during inguinal LND
"Femoral artery, superficial circumflex (lateral), superficial external pudendal (medial), superficial epigastric (superior), -- and saphenous v!!! Answer is which is not: deep circumflex femoral"
101
Vesicants: question was which is not - answer was taxotere
ADMVY - actino, doxo, mito, vincas, yondelis (trabectedin)
102
VEGF roles
Capillary tube formation; key factor in blood vessel development and permeability; on endothelial cells
103
Vaginal cancer: 1 cm posterior vaginal fornix, hx Crohn's disease
Rad hyst + LND + vaginectomy (this one); partial resection +LND; radical local excision; radiation combination
104
Use of amifostine
"Decrease neurotoxicity of cisplatin / and decrease BM and nephrotox of cisplatin and cytoxan Prodrug that acts as a free radical scavenger and tends to be selective to non-malignant tissues"
105
Type II error
Erronerously not rejecting null hypothesis (like false negative); beta; related to power = 1 - beta
106
Type I error
Erronerously rejects null hypothesis (like false positive) - this is sort of worse; alpha (ype I error is to falsely infer the existence of something that is not there, while a type II error is to falsely infer the absence of something that is.)
107
Type 2 endometrial cancer associated with what mutations? And pap serous ovary
p53 and Her2 (CORRECT), others - MLH and p53, PMS2 and Her2
108
Tx of microinvasive cervix cancer
CKC
109
Tx of LCIS
"If needle bx, need to excise; if excisional bx, no addtl surgery; traditionally, ppl got ppx mastectomtimes but now use chemoprevention (i.e., tam or AI)"
110
Tx of HYPERmagnesemia
Fluids and loop diuretic (i.e., lasix) this one - calcium, othe rchoices
111
Tx for solitary ESS lung nodule
Surgery (this one), megace, letrazole, xrt, tamox - if were to use hormonal would use megace/letrazole or GnRH agonist
112
Tx for initial recurrence of cdiff
depends what treated with first: if first treated with vanco and recurs try pulsed vanco dosing or fidaxomicin or flagyl Repeat PO flagyl (if mild) or PO vanco (if severe); alternative: fidaxomicin PO; more than two relapses consider fecal microbiota transplant
113
Tx for advanced stage cervical cancer
Real answer GOG 240: Cis/taxol/bev; GOG204 cis/taxol won out of cis/vinorelbine, cisgem, cis/topo; JGOG0505 says carbo/taxol ok
114
Two main branches from the external iliac and terminal branch
Inferior epigastric a and deep iliac circumflex; terminal branch = femoral a
115
Tumor marker least likely to be affected by pregnancy
LDH (this one), hCG, CA-125, inhibin
116
Tumor lysis syndrome
"Hyperkalemia, Hyperphosphatemia / Secondary hypocalcemia / Hyperuricemia due to catabolism of nucleic acids Acute kidney injury (uric acid precipitates in calcium phosphate and vice versa!) Occurs in tumors with high proliferative rate, large tumor burden, or high sensitivity to cytotoxic therapy Other sx: nausea/vomiting, diarrhea, anorexia, lethargy, hematuria, heart failure, cardiac arrhythmia, sz, cramps, tetany, syncope, sudden death Tx: supportive care, electrolyte optimization, allopurinol or rasburicase to lower serum uric acid"
117
Treatment options for c.diff
PO Flagyl or PO Vanco or Fidaxomicin
118
Treatment of stage IVB cervix cancer
Depends on sx: palliative chemo if bleeding not an issue, if so then chemorads
119
Treatment of non-healing vulvar ulcer or hemorrhagic cystitis after xrt
Hyperbaric oxygen
120
Treatment of cystitis during xrt
Oxybutinin (anti-cholinergic, antagonizes M1, M2, M3 receptors of Ach receptor), if chronic then observe
121
Treatment for HCAP
" CEFEPIME (4TH GEN), ZOSYN, OR LEVOFLOXACIN IV (reserve IMIPENEM for ESBL) IF LOW RISK ADD AG IF HIGH RISK DOUBLE COVERAGE FOR PSEUDOMONAS (amikacin, gentamycin or tobramycin) ADD VANCO IF HIGH RISK FOR MRSA, RECENT IV ABX if low risk mort (i.e., no vent or sepsis) and no MRSA factors: IV zosyn, IV cefepime (4th gen), IV levquin, IV imipenem/meropenema If high risk mort and no MRSA factors: dual therapy with above + add IV fluoroquinolone or aminoglycoside (these add Pseudomonas coverage) If MRSA (tx'ed IV abx last 90 days or >20% in unit), add IV vanco or IV linezolid to above If high risk mortality or IV abx last 90d: need 2 abx but now can consider gent or tobra (both AGs) or aztreonam (avoid beta-lactams) from above PLUS vanco see sheet 2"
122
Transected IMA
Ligate and continue with surgery
123
Torsades de pointes is associated with #1 and total 3 electrolyte abnormalities
1) hypomag - then hypok (often result of hypomag) - then hypoCa
124
Timing of splenectomy vaccination
At least 14d before, otherwise 14d after
125
Temporary clamp on ureter, what to do
Stent
126
Taxol 24 vs. 3 hours
Less neurotoxicity for 24 hours but more BM toxicity
127
Target for areprepitant
NK1 receptor (located centrally and peripherally); dominant ligand is substance P
128
Sx of HYPERmag (think of pre-e duh)
"4-6: nausea, HA, drowsy, diminished DTR; 6-10: somnolence, hypocalcemia, absent DTR, brady, prolonged QT, hypotension; >10 flaccid quadriplegia, apnea, resp failure, cardiac arrest, complete heart blck (resp failure precedes cardiac collapse)"
129
Survival analysis
Kaplan Meier curves / and then Cox proportional hazards to see if they are diferent?
130
Strategies to reduce nephrotoxicity of chemo
Dose reduce, hydration, eliminate other nephrotoxic drugs
131
Statistical test used for evaluation of independent variables
Logistic regression
132
Statistical test to evaluate continuous variables in normally distributed population
Unpaired t-test
133
Statistical test for comparing the means of 3 variables
ANOVA
134
"Statistical test for comparing nominal aka categorical variables in a normally distributed population "
Chi-squared (this one- is non-parametric), wilcoxon, t test
135
Statistical analysis for before and after intervention (i.e., BP readings)
Paired t-test
136
Staining if ovarian met from colon
CK7 neg, C20 pos for colon cancer whereas ovary CK7 pos, CK20 neg
137
Staging for endometrial cancer - glandular involvment, cytology, 40% myometrial invasion: IA, IB, II, IIIA
Stage IA
138
Stage I endodermal sinus tumor @ 18 weeks s/p surgery. Best step now?
Immediate chemo
139
Specific mechanism of action for bev
Inhibints VEGF-A it directly binds it (NOT THE RECEPTOR!!!!!)
140
Someone with HPV, what is most important other co-factor
Smoking (this one), OCPs, multiple partners, age at first coitus
141
"Sixteen week pregnant patient has adnexal mass removed which is consistent with yolk sac tumor what do you do A. start chemo B. observe C. other options"
Start chemo
142
Side effect LEAST likely to be minimized when choosing AI over tamoxifen
"Reduce osteoporosis fractures, MSK pain Tamox SE: endometrial cancer, vag bleeding, VTE/CVA, hot flashes - anti-est in breast, pro everywhere else (uterus, bone, liver, coagulation system) AI: hot flashes, osteopenia or osteoporosis, bone pain, diarrhea"
143
What is mechanism of hypotension in septic shock?
Increased venous capacitance
144
Screening for HNPNCC
"CRC (50-80% risk) - colonoscopy between ages 20-25 or 2-5 years before youngest dx in family, every 1-2 yrs Endom (16-60% risk) - no definite evidence of EMBx or US; can consider TAH/BSO after childbearing Stomach/small bowel- EGD every 3-5 years starting age 30-35 for certain (i..e, Asian, MLH1, MSH2, EPCAM), H.pylor testing/treating Urothelial- consider annual UA (i.e., MLH1, MSH2, EPCAM) Pancreatic- none CNS- none"
145
Route/course of femoral nere
"From posterior the posoas and emerges at lower part of lateral border, between psoas and iliacus muscle, beneath inguinal ligament under the intuinal ligament (femoral triangle)"
146
Role of PET CT in cervical cancer
Eval distant mets (THIS ONE), bladder involvement, side wall involvement
147
Risks factors for GTD
"age <20 (this one), blood type O, two other choices From lit: extremes maternal age, OB hx prior molar pregnancy or SAB, diet low in animal fat/carotene/vitA, blood type A or AB"
148
Risk factors for lymphedema
"RF: Obesity, # LN removed, extent or surgery, postop infxn, radiation tx, postop DVT 20% in pt with hyst + LND; higher for inguinal LND 30%?"
149
Rectosigmoid - distal stenosis after radiation, mgmt
Progressive dilation (this one), loop colostomy, LAR with Hartman's pouch, other
150
Ratio of tumor markers for ovca and colon cancer
CA125/CEA (this one, 25:1), HE4/CEA
151
Pt with uterine cancer, get in and there is sidewall disease - what do you do?
Exent, rad hyst, oophorectomy then XRT (this one)
152
Pt with UPT+, hyperglycos hCG neg, plateaus after 3 cycles mtx at 145-150 hCG - next step?
"Observe (THIS ONE because quiescent GTD), actD, other chemo, hyst"
153
Pt with elevated serum hCG no other signs of GTD, what is next step?
"uPT (to r/o phantom hCG - this one), repeat serum hCG, free hcG, other option due to heterophilic Ab which are not excreted in the urine"
154
Pt on tam x 2 years, 8 weeks pregnant: what do you recommend
termination, d/c tam for pregnancy and breast feeding (we think this one?), continue tam; class D - d/c for pregnancy and breast feeding
155
Pt on BEP with pulm sx, what do you do first
Stop bleo
156
Psuedomonas UTI - which does not cover
"Amox (this one) What does cover: zosyn, ceftaz or cefepime, aztreonam, cipro (not as much other fluroquinolones), meropenem/doripenem (not as much imipenem) AG but need dual therapy Oral: pick cipro (or levoquin)"
157
Proposed mechanism of synergy b/t chemo and angiogenesis inhibitors
"""Normalization"" theory - anti-angiogeneic agent restores normal blood flow and reduces tumor interstitial fluid pressure favoring the penetration fo cytoroxic agents"
158
Prodrugs: which is not (and list which are common prodrugs)
"gemzar, 5FU, taxotere (THIS ONE) Prodrugs: cyclophosphamide, ifosfamide, capecitabine aka xeloda (most need to be activated in the liver); gemcitabine"
159
Prerenal; equation for FeNa?
"know variables NaU x CrP / NaP x CrU FeNa <1% also will have elevated BUN:Cr ratio (i.e., 20:1)"
160
Pregnant pt, cone bx stage IA1 squamous cervical cancer neg margins
Observe
161
Pregnant pt cone bx CIS, + margins, pos ECC - what to do?
Observe
162
Predictor of mortality in sepsis
Sustained tachycardia
163
PPV affected by what
"Prevalence (whereas, likelihood ratios do not depend on prevalence) Higher prevalence will increase PPV and decrease NPV; no impact on sensitivity or specificity"
164
Postop pt VSS and afib: MTP, anticoagulation, digoxin, 1 other choirces
MTP, not anticoagulation since immediately postop
165
Poor ovca prognostic factor
VEGF-D assoc with higher stage, LVSI, LN, etc
166
"Point A Point B (Manchester system)"
"Point A = 2 cm lateral to central canal of uterus and 2 cm from lateral fornix in axis of uterus (where ureter crosses uterine artery, avg point from which to assess dose in paracervical region) Point B = 5 cm from midline at level of point A aka 3 cm lateral to point A (correspond to obturator nodes)"
167
Picture of uterine cancer histology
pap serous (this one), LMS, endometrioid (it looked like this pic: http://www.bing.com/images/search?q=uterine+pap+serous&view=detailv2&&&id=C623DA18BA5FA8F3CDEA7B7C6DA2246C44C208EB&selectedIndex=0&ccid=mEKMHxbh&simid=608009031462355063&thid=JN.4U8pNODF%2flIE%2blTiwcxONA&ajaxhist=0)
168
PI3K/AKT/mTOR pathway
"PI3K phosphorylate phosphoinositides (Pis), main effectors through interaction of receptor tyrosine kinase and G protein-coupled receptors Downstream effectors = AKT and mTOR PI3K-AKT pathway promotes cell growth/survival and inhibits apoptosis and autophagy AKT activates mTOR (mammalian target of rapamycin) - modulates genes that inhibit cell cycle progression (CHK1, MDM2) - pro-apoptotic (BAD, BAX) - inhibits BAD BIM and p53 - nuclear translocation and activation of transcription factor NF-KB pro-survival genes"
169
Peutz Jeghers - germline mutation
STK11(this one).PTEN, p53
170
"Peutz Jeghers What is the clinical picture? What cancers are they at risk for? What screening test is not needed?"
"Clinical picture: GI polyps, pigmented lesions on lips/mouth Cancer risk: GI and breast cancer Gyn issues: SCTAT (sex cord stromal tumors with annnular tumors of ovary) and adenoma malignum of the cervix Colonoscopy, pap smears, ultrasound, EMB (THIS ONE), breast imaging "
171
PEEP and ARDS
high peep strategy: PEEP 10-15 most important variable
172
Peak level IP vs. IV bioavailability for carbo
1:5, 1:20, 1:5000 (??); Barakat - 10:1 IP vs IV concentration in peritoneal cavity
173
PE postop patient with renal failure (CrCl 20)
heparing (this one), IVC filter, LMWH (can dose 1 mg/kg daily rather than 1 mg/kg BID or 1.5 mg/kg daily but not if <30)
174
PE on anticoagulation
"Are they actually therapeutic? Switch to lovenox if on warfarin. Increase lovenox dose. Consider IVC filter Anti-Xa and direct thrombin inhibitors is unstudied in this population"
175
"Patient with 1 cm vulvar cancer with two positive lymph nodes in right groin, what is postop treatment? A. Bilateral groin xrt B. Groin LND and pelvic xrt C. Two other choices"
B. bilateral groin and pelvic XRT
176
Partial (vs complete) mole
PARTLY paternal, triploid, fetus often present, focal edema (rather than diffuse), rare med complications, SGA, <5% malignant sequelae
177
PARP inhibitor mechanism
Causes ss dna breaks that can't be repaired by BRCA defective cells; TL: blocks base excision repair (BER), which is responsible for ss DNA breaks; these convert to ds DNA breaks, which cannot be repaired by patients with hemologous recombination deficiency (HRD)
178
PARP
Homologous recombination target
179
Pancreatic leak seen postoperatively, how to manage
Percutaneous drain
180
p53 mutation
"deactivates proteins (??) DNA-binding ability of mutant p53 or changes in interaction of mutant p53 with proteins (esp transcription factors) or other proteins normal activity of p53- binds to transcriptional regulatory elements of genes that act to arrest cells in G1 cancer often have missense mutations in 1 copy of TP53 gene does NOT require inactivation of both TP53 alleles, so acts in ""dominant negative"" fashion b/c if cancer cell has one normal TP53, the mutant can complex with it to prevent it from oligimerizing and interacting with DNA inhibits proliferation also stimulates apoptosis cells that have excessive genetic damage ""guardian of the genome"" bc delays entry into S phase until genome has been cleansed of mutations"
181
Outpatient treatment for neutropenic fever
"PO cipro + PO augmentin (do NOT use cipro alone); can consider PO levaquin alone but less potent anti-Pseudomonal Can use validated MASC score (low risk if cumulative >/= 21); see sheet 2"
182
Origin of middle rectal artery
Internal iliac, anterior division
183
Old lady died after unvaccinated and splenectomy done
Encapsulated organisms: Mengigococcus, H. flu, Strep pneumo*
184
Non-parametric tests and their parametric counterparts
"Independent samples t-test --> Mann-Whitney U test (rank sum) Paired samples t-test --> Wilcoxon signed rank test ANOVA --> Kruskal-Wallis Pearson's correlation --> Spearman's correlation"
185
Non-anion gap acidosis
Pancreatic leak
186
Non-epithelial ovarian cancer that sometimes needs secondary cytoreduction
"Immature teratoma (THIS ONE), MMMT Cases where pt received adj chemo for immature teratoma and have bulky residual even w/ normaliztion of negtive markers; reasonable to do surgery; sometimes path during secondary debulk with not be malignant then observe, if malignant viable tissue then addtll chemo"
187
Nerves in the femoral triangle
Femoral nerve, ilioinguinal (?) toward deep inguinal ring, fem branch of genfem; TL: (in order lateral to medial) lateral cutaneous nerve of thigh, femoral nerve, nerve to pectineus, femoral branch of genitofemoral nerve
188
Nerve supply to vulva
Pudendal nerve and genital branch of genfem
189
Napsin A (IHC stain)
Clear cell carcinoma
190
MSI (group 2), MSS (group 3 - PTEN, ARID1A)
Most common methylation of MLH1; MLH1 + PMS2, MSH2 + MSH6 form dimers so if one degraded the other is
191
Most unlikely side effect of bev
"Hypotension (7-15%), GI perf (life-threatening but actually rare; 0.3-3.2%), bleeding (40%), HA (22-37%) fyi Hypertension HTN (12-34%), VTE (6-9%), thrombosis (8-10%), proteinuria (4-36%), low EF (1% - might pick this if option)"
192
Most sensitive/specific test for cdiff
Stool toxin culture
193
Most sensitive test to r/o CHF in woman with dyspnea postop
BNP <100 (this one), CXR, no LE edema, low CVP
194
Most reliable way to confirm endotracheal tube is in correct position
Distance, pCO2, O2 sat, mmHg (answer = end tital CO2 40 mmHg)
195
Most predictive of pulm complication after surgery
FEV1 < 1000cc b/c normal is 3-4L, FEV1/FVC below the 5th percentile for healthy non-smoker = bad; and FEV1 <80% predicted = bad
196
Most likely to present as hemoperitoneum
Granulosa cell tumor (this one), dysgerminoma, etc
197
Most likely to have ureteral obst
Rad + extrafascial hyst; rad hyst + rads (this one), radiaton
198
Most likely to be helpful in n/v from gastric outlet obstruction
Somatostatin (this one), 5HT blocker, narcotic
199
Most likely to be associated with lymphatic spread
Adenosarcoma, MMMT (this one), uLMS, undiff sarcoma
200
Most likely risk factor for postop lung infection or pulm comp (?)
Pulm edema, low vertical incision, EBL, nutrition (low albumin associated with post-op PNA)
201
Most likely means to transmit cdiff
Not washing hands b/t patients
202
Most likely complication from subclavian line placement
Pneumothorax; NEJM 1994 misplacement (6%), arterial puncture (3.7%), PTX (1.5%), mediastinal hematoma (0.6%)
203
"Most likely associated with lymph node mets? A. Dysgerminoma B. Sertoli-leydig c. Granulosa cell d. Immature teratoma"
"A. Dysgerminoma (28%) - very chemosensitive mixed germ cell (16%), malignant teratoma (8%) - uptodate Rare LN involvement in sex cord stromal tumors "
204
Most lethal impact of radiation
Double strand break; other options: single strand break, 2 other choices
205
Most impt prognostic factor endometrial cancer
Obesity
206
Most emetogenic
"Per NCCN: high risk = Anthracycline (ie. Doxorubicin), cyclophosphamide (or ifosfamide), Carbo AUC >4, cis Actinomycin D = moderate risk"
207
Most diagnostic of ARDS
Bilateral pulm infiltrates, Pa/FiO2 ratio <200 (this one), two other choices
208
Most common TPN risk
Hyperglycemia
209
Most common sx of GCSF
bone pain
210
Most common sx from long term electrolyte abnormalities from cisplatin
Muscle weakness, peripheral neuropathy (THIS ONE)
211
Most common sx after axillary LN dissection
"Lymphadema, numbness of arm (this one) Up to 42% had subjective/objective arm impariment one year after (uptodate)"
212
Most common side effect of megace
breast tenderness, weight gain (THIS ONE), hyperglycemia, hypercholesteremia
213
Most common risk factor for radiation enteritis
"Prior abd surgery, chemorads (this one?), age (higher risk if older), cervical cancer, higher obesity (no, higher risk in skinny people) Pubmed search - Summary of risk factors for GI RT injury: *RT techniques: tx volume, total dose, fractionation dose and schedule *Combined modality therapies: surgery, chemo (particularly concurrent) *Medical co-morbidities: vascular disease, connective tissue disease, inflammatory bowel ,HIV *Genetic susceptibility: single nucleotide polymorphism, ataxia telangiectasia"
214
Most common reason for hyperkalemia postop
renal dysfunction
215
Most common ovarian tumor (not cancer) in pregnancy
Non-malignant teratoma
216
Most common ovarian tumor (cancer) in pregnancy
Germ cell tumors (40%) - choices LMP, ESS, dysgerm, EOC (this one)
217
Most common organ with toxicity in HDR (or any pelvic radiation)
Rectum
218
Most common mechanism of oncogene activation
"1) mutation (in promoter) 2) gene amplification (probably this one) 3) chromosome rearrangement TL: Lit search suggests that gene amplification is the correct answer"
219
Most common malignancy in young women
"juvenile granulosa cell, sertoli leydig, borderline (this one of these options) Germ cells most common with dysgerm 40% of those -- LMP of the choices"
220
Most common HPV type with ADENOCARCINOMA OF THE CervIX
18 (this one), 6/11/16 - 18
221
Most common germline ov ca mutation
p53, BRCA 1 (THIS ONE), BRCA 2
222
Most common electrolyte disturbance from urinary diversion
Excess chloride (absorption of excreted metabolites through intestinal mucosa); leads to metaboilc acidosis
223
Most common cuase of ilioinguinal nerve injury
Transverse incision (this one), retractor, hyperflexion
224
Most common cause not seeing SBO on x-ray
High/proximal obst (this one), NGT drainage, perforation (would see free air)
225
Most common cause incorrect surgical count
"Change RN staff (this one), multiple surgeries, long operation, obesity TL: According to the sentinel event data, the most common root cause of URFOs reportd to the Joint Commission are: absence of policies/procedures, failure to comply with policies/procedures, problems with hierarchy and intimidation, failure in communication with physicians, failure of staff to communicate relevant patient information (hopefully there will be a systems failure option)"
226
Most common complication of transverse loop colostomy
Retraction, stricture, parastomal hernia, prolapse (this one most common); #1 is skin irritation if choice (vs retraction for end)
227
Most common complication of HIT
Thrombosis (this one), hypersplenism, ARF
228
Most common complication continent ileal conduit
"Can't cath aka stomal stricture (2-14%, this one), leaking (short term 2-10%), stone formation (3% upper tract, 5-35% pouch calculi) --- LEAKING??? infection early 1-13%, late 3-10% TL: Lit search suggests the answer is stricture"
229
Most common cause of prolonged metabolic alkalosis?
"Sheet says: NG tube two most common causes of metabolic alkalosis in general are loss of gastric acid (vomiting, NG drainage) and diuretics (specifically furosemide and thiazides)"
230
Most common acute tox of IP chemo
Abdominal pain
231
Most calories from TPN come from…
Glucose (40-80%) - this one, fat (15-60%), protein
232
MicroRNA when bind to 3UTP region - targeted mechanism of action
"inhibit transcription? microRNA = small non-coding RNA that functions in RNA silences and post-transcriptional regulation of gene expression silencing? TL: ""Gene silencing may occur either via mRNA degradation or preventing mRNA from being translated. For example, miR16 contains a sequence complementary to the AU-rich element found in the 3'UTR of many unstable mRNAs, such as TNF alpha or GM-CSF.[87] It has been demonstrated that given complete complementarity between the miRNA and target mRNA sequence, Ago2 can cleave the mRNA and lead to direct mRNA degradation. Absent complementarity, silencing is achieved by preventing translation."""
233
Micromet in sentinel inguinal LN - what to do
rads (this one), full LND (only if bulky since need rads anyway), obs
234
Mgmt of ureteral injury at ureterovesical junction
"Options: ureteroneocystotomy (this one), Boari, uretero-uretero Lower ureter 90% (ureteroureterostomy vs ureteroneocystotomy), psoas hitch ureteral reimplantation helps if cannot do either of the prior w/o tension) Middle ureter 7% (Boari flap, transureterureterostomy) Upper ureter 2% (nephrostomy, nephrectomy, autotransplation, ileal or appendiceal interpositoin graft)"
235
Mechanisms of platinum resistance
"1) Downregulation of CTR1 transporter (reduced intracellular accumulation of platinum) 2) Elevated levels of cellular glutathione (GSH) inhibits gamma-glutamylcystein synthestase (basically, intracellular inactivation) which reduces GSH trying to restore drug sensitivity 3) Nuclear excision repair (NER) pathway which repairs platinum-DNA adducts through ERCC1 protein THIS MOST COMMON**** 4) DNA MMR - loss of function of MMR contributes to developing DNA damage tolerance"
236
Mechanisms of nausea and receptors drugs target/act on
"Muscarinic - scopolamine H1 - benadryl, dramamine D2 - prochlorperazine (compazine, metoclopramie (reglan) 5HT3- zofran, palonsetron NK-1- aprepitant GABA - benzos"
237
Mechanism of cisplatin with radiation
"Cell repair inhibited Mechiansm of action: binding with DNA causing INTRAstand cross-links and DNA adducts"
238
Mechanism of action: topotecan
Inhibit TOPO-I (a nuclear enzyme that relieves torsional strain in DNA by opening single strand breaks); forms stabilized ternary topotecan-TOPO-I-DNA complex with replication enzymes which results in dsDNA breaks and cellular death
239
Mechanism of action: methotrexate
"Mtx binds to DHF (dihydrofolate reductase) blocking DHF-->THF (which is active form of folic acid) As a result, thymidylate synthetase and other steps in de novo purine synthesis that require 1-carbon transfer rxn are halted This arrests DNA, RNA and protein synthesis"
240
Mechanism of action: gemcitabine
"Prodrug --> into triphosphate and diphosphate metabolites Triphosphate metabolite incorporated into DNA as fradulent base pair, leading to addtl deoxynucleotide at end of DNA replication is terminated (called ""MASKED CHAIN TERMINATION) which prevents exonucleases from excising fradulent base pair Diphosphate metabolite inhibits ribonucleotide reductive which depletes deoxynucleotide pools necessary for DNR synth/repair"
241
Mechanism of action: etoposide
"Inhibits TOPO-II enzymes (does NOT bind directly to DNA rather stabilizes transition form of DNA-TOPII / by stabilizing this it ""poisons"" TOPOII enzymes which usually helps cells progress out of G2"
242
"Mechanism of action: doxorubicin Limit dose to what?"
"Anthracycline antibiotic from Streptomyces peucetius 1) DNA binding and intercalating, inhibiting DNA synthesis (S phase) 2) Free radical formation - this may be related to the cardiotoxicity 3) Inhibition of DNA topoisomerase II by inhibiting strand-passing activity of topo-II (acts in G2 phase) topo I, free radicals (yes), intercalating (yes), DNA adducts Limit dose to 550 mg/m2 cumulative life dose"
243
Mechanism of action: acyclovir
"Synthetic purine nucleoSIDE analog (aka sugar+base, no phosphate which is needed to be nucleotide); substrate specific for HSV and VZV-specified THYMIDINE KINASE needs to be phosphorylated intracellulary to become active converted to monophosphate by viral THYMIDINE KINASE, then to diphosphate by cellular guanylate kinase, then to triphosphate with othe renzymes acyclovir triphosphate stops replication by 1) competitive inhibition of viral DNA POLYMERASE, 2) incorporation into and termination of growing viral DNA chain, 3) inactivation of viral DNA polymerase"
244
Mechanism of action lovenox
Enoxaparin binds to and potentiates antithrombin (a circulating anticoagulant) to form a complex that irreversibly inactivates clotting factor Xa.[13] It has less activity against factor IIa (thrombin) compared to unfractionated heparin (UFH) due to its low molecular weight
245
Mechanism of action for bisphosphonates
Inhibit osteoclastic bone resorption (primary) -- also reduce decreased osteoclast progenitor development and recruitment by promoting osteoclast apoptosis
246
Mechanism by which tumor suppressor genes are deactivated
Methylation
247
Manifestations of hypoMg
Neuromuscular hyperexcitability (tremor, tetany, sz, up to coma), CV (widened QRS and peaked t-waves),
248
Main differences between HDR and LDR
"LDR is 0.4-2.0 Gy per hour vs HDR is >12 Gy per hour More fractions and dose for HDR - perhaps ""better tumor control"" b/c less time for tumor to repair? but studies equivocol bt overall LESS TX TIME Less fractions and dose for LDR - better tissue repair esp for ""late responding tissues"" LDR where radioactive source positioned inside for a few days vs HDR remporary placement of radioactive source; more precise "
249
Main blood supply to the jejenum
SMA
250
Lowest breast cancer risk
Chest rads age 17 is 1.5x (this one), Cowden, Li-Fraumeni, 1st degree relative with BRCA2
251
Lots of HNPCC what are the most common MMR defects?
MLH1/MSH2 (this one); PMS2, MSH6
252
LMS staging - IB is what size cut off
5cm
253
LMP tumor - how to differentiate nonmetastic vs. metastatic implant
"stroma reaction (THIS ONE), papillations, cytologic atypia, mitotic index proliferative epithelium with infiltrating margin and desmoplastic stroma that resembles low-grade serous carcinoma Serous tumors of low malignant potential, characterized by broad, branching papillae (hierarchical branching) focally covered by stratified epithelium with mild to moderate atypia with few mitoses "
254
Liver and renal clearance: one question each asking which agent is not dose adjusted
"BICC THEM, MTV3D (2 questions) "
255
Leukemogenic
"etopsoside, platin, 5FU - melphelan (this one) TL: But so is etoposide"
256
Left hemicolectomy and needs diversion
Ileostomy
257
Least thermal injry
pure unblend cut (this one), blend, spray
258
Least recommended colon ca screening for lynch/HNPCC
Sigmoidoscopy aka flex sig (b/c could have right sided tumors)
259
Least protein bound chemo
"Highly protein bound ie to albumin? (95% protein binding: cis, taxol, docetaxel, etoposide, active metab of irinotecan) Least protein bound: doxorubicin (75%), topotecan (35%), gem (10%), carbo (<5%), ifos (<5%) Free drug (non-protein bound) is what mediates toxicity TL: high - doxorubicin, MTX, cis; low - gem"
260
Least likely reason for afib
Anemia (this one), hypoxia, electrolyte imbalance, PE
261
Least leukemogenic
"Cisplatin, melphalan, cytoxan, 5-FU (this one)--> def cytoxan and melphelan are cytotoxic TL: leukemogenic - cyclophosphamide, etoposide, melphalan (other non-gyn: chlorambucil, (methyl) CCNU, BCNU, DTIC - all are alkylating agents)"
262
Least emetogenecity
Vinca (THIS ONE), carbo, doxo, dactino
263
Least efficaceous combo tx in carcinosarcoma
Gem/tax (this one), ifos/cis, ifos/taxol, carbo/taxol
264
Least cumulative bone marrow
cisplatin, cytoxan (myelosuppression is dose limiting, leukopenia), carbo (thrombocytopenia), taxol (we chose taxol)
265
Least bone marrow suprresive
Bleomycin (main dose-limiting side effect is pulm tox, 10%; nephrotoxicity)
266
Least associated with germline mutation
p53, HER2 (this one- overamplification), APC (assoc with familiar adenomatous polyposis), MSH2
267
Lacerated IMA
Cauterize, tamponade, and monitor
268
KRAS
also associated with mucinous histology ; assoc with recurrent low grade serous carcinoma (but not BRAF)
269
Kappa, what # is good
Kappa for intrter-observe agreement, want it to be 1 ideally
270
Just completed radiation, perforated sigmoid and feculent
Loop ileostomy, end ileostomy, rectosigmoidectomy with end stoma (this one??)
271
IP chemo pharmacokinetics
"Generally - IP chemo should be LARGER, HYDROPHILIS, IONIZED - b/c clear more slowly from peritoneal cavity and cancer maintain concentration; penetrate tumor nodules through PASSIVE diffusion (up to 2-3 mm) but that's why we cytoreduce"
272
Interleukins were first discovered by
Seen as signal molecules between WBC/leukocytes
273
Integrin role in cancer
"metastases role (cell invasion and migration) adhesion of leukocytes to endothelial cells"
274
Inpatient treatment for neutropenic fever
"Need to cover Pseudomonas and other gram neg IV monotherapy ie., cefepime, imipenem or meropenem, or zosyn (IDSA 2010 guidelines) Do not need vanco or aminoglycoside unless there is a clear clinical indication"
275
Infection assoc with spreading erythema, raised borders, lymphangitis
Nec fasc, gas gangrene, strep pyogenes - aka erysipelas (this one), staph
276
Inappropriate abx for neutropenic fever
Ceftriaxone (3rd gen)
277
Immediate tx for hyperkalemia in Stage III cerivcla cancer pt
"lasix (loop diuretic), insulin/glucose (THIS ONE), dialysis, kayexelate Dosing FYI: 10 units bolus insulin then 50 cc of 50% dextrose (25g glucose)"
278
Immature teratoma
May be assoc with small cell carcinoma of the ovary (w/ hypercalcemia); or chromosomal abnormalities
279
Imatinib
ckit (also known as gleevec)
280
"IMA collateral Which is not?"
"SMA and IMA communicate via marginal a. of Drummond (spleneic flexure and arc of Riolan aka meandering mesenteric artery is collateral that connectes the middle and left colic artery in the LUQ); but since absent/underdeveloped in 5% places splenic flexure at risk of ischemia IMA and internal iliac a. communicate via superior and middle/inferior rectal (hemorrhoidal) arteries (thus, rectum has dual blood supply from mesenteric and iliac arteries so more resistant to ischemia) Ext iliac, int iliac (def is), pancreaticoduodenal (THIS ONE)"
281
If you conduct a trial and get p<0.01 which are true EXCEPT
study was significant, smaller sample size may have resulted in non-significant finding, reject the null, you didn't have enough power (this one)
282
If ov cancer patient + abdom tumor burden has lot 10% body weight in 1 month, what is biggest concern re: taxol toxicity
Hepatic metabolism then biliary excretion (70-80% of drug eliminated by fecal excretion)
283
Hyponatremia - most concerning sx
confusion (THIS ONE), HA
284
High urine Na > 40, high urine osmolality > 300
SIADH, severe hypothyroid, cortisol deficiency
285
Low urine Na <25, low urine osm < 100
primary polydipsia, malnutrition potomania, surreptitious diuretic use
286
Hypocalcemia: know side effects - one of each asked
"PROLONGED QT (this one), hyperreflexia #1 = tetany; others- seizure, hypotension, prolonged QT, papilledema, psychological sx (less common confusion)"
287
Hypercalcemia sx
"SHORTENED QT (this one) mild Ca <12 asx or non-specific constipation, ftigue, depression moderate 12-14 polyuria, polydipsia (b/c can't concentrate urine), dehydration, anorexia, nausea, m. weakness, snesorium changes severe Ca >14 progression"
288
Hypercalcemia - which is not a treatment
"D5W (this one) tx (mild) - hydrate with NS (NOT WATER), avoid thiazide diuretics tx (severe) - isotonic saline vol expansion, calcitonin, zoledronic acid; if refractory, can try denosumab"
289
How to tx DVT if renal failure
Don't use lovenox --> can use coumadin or argatroban or heparin or apixiban
290
How to reduce small bowel complications with radiation
Tx with fll bladder, prone position (this one? Def better than supine, TL: correct based on lit search), decubitus position
291
How to reduce PPE sx
Cold packs, emoillents, B6, dose reduction, vitamin E
292
How to control for confounding
Multivariate logistic regression
293
How to check impact of independent variable
Logistic regression
294
How had addition of chemosensitizers affect radiation outcomes
"enterocolitis, noninfectious bladder cystitis, fistula formation, mortality (or this one? TL: I think its this one.) In meta-analysis 2010 / HR death 0.69 or 10% absolute improvement, HR recurrence 0.66 (13% absolute improvement, OR 1.98 gr 3/4 esp GI tox)"
295
How does the HPV vaccine work
"Recombinant L1 capsid protein (1 of 2 viral capsid proteins) Forms virus like particles (VLPs) which are combined with adjuvants Adjuvants stimulate the immune system (aluminum based) VLPs induce humoral response with antbiotides and some cell-mediated immune response"
296
How does LOH occur (two mechanisms)
Deletion most common, or methylation
297
How does her2 work
Oncogene that is activated by AMPLIFICATION
298
How does cisplatin augment radiation
Inhibit repair of sublethal damage
299
How do kinases work
Phosphorylation
300
HNPCC not cancer - long list
"breast // does include endometrial, colon, gastric, ovarian, pancreatic, uretehral, brain (glioblastoma), small intestinal, sebaceous gland adenomatous polyps, keratoacanthomas"
301
"HIT II pt - next best step vs HIT I where plt ~100K, not immune-mediated, and can continue heparin"
"argatroban=direct thrombin inhibitor (THIS ONE- and ok in renal failure), heparin, warfarin can also consider fondaparinux=inhibits anti-Xa activity through antithrombin III, synthetic or if liver failure, use bivalirudin (also a direct thrombin inhibitor) occurs in 5% of pt exposed to heparin, anti-PF4 (platelet factor 4) thrombocytopenia = plt <150K plt drop usu >50% baseline, occurs 5-10d after exposure (could be earlier if recently exposed to heparin) THROMBOSIS (50% those with HIT, venous > arterial, can lead to skin necrosis, limb gangrene, organ infarction) resolution after stopping heparin is usually 7d"
302
Histopath of leiomyosarcoma
LMS - have prominent cellular atypia, abundant mitoses (≥10 per 10 high power fields), and areas of coagulative necrosis. NOT infiltrative borders
303
Highest risk for VRAM flap
Prior surgery (this one - prior Maylard?), smoking, obesity
304
High LET has what effect on cancer cells?
Tumor necrosis
305
HAMA (human anti-mouse antibody) - most likely to get immune response
"longer oligonucleiotide fragment, chimeric human ab, part of human something or other where you just replicate a piece of murine DNA and create human copy"
306
GTN - quiescent versus active
"Persistent, unchanging low levels M200 of real hcG for at least 3 months with hx of GTD or SAB but no detectable disease 6-25% will develop active disease (increase in hyperglycosylated hCG with cytotrophoblastic invasion) and total hCT Only tx once sustained rise or overt clinical disease detected"
307
Grade 3, IA endometrioid ovarian cancer
observation, 3 cycles chemo (THIS ONE based on GOG157), 6 cycles chemo
308
Grade 1 endometrioid, young, normal weight - most likely expression
MSH2 (this one), CK7, ER, PR
309
Germ cell tumor least likely to have elvated AFP
Dysgerminoma and choriocarcinoma both not elevated
310
Genetic mut associated with type I endometrial cancer
PTEN (PTEN tumor suppressor is the most important negative regulator of PI3K signaling)
311
Genes related to apoptosis
"bcl (b cell lymphoma) - regulate apoptosis caspase - programmed cell death including apoptosis BAX (bcel-2 like protein 4) encoded by BAX gene - regulate apoptosis NOT VEGF"
312
GAIL model criteria
"a. Age b. Age of menarch c. Age at first live birth d. Number of first degree relatives with breast cancer e. Number of prior breast biopsies f. H/o atypical hyperplasia (of the breast)"
313
Formula for odds ratio (OR) vs. relative risk (and when to use each)
"(a/b) / (c/d) or (a*d)/(b*c) i.e., gave numerator (exposed case/unexp case) and you give denominator (exp control/unexp control) see 4x4 table on next page RR = a/(a+b) / c/(c+d) Use OR for case control (b/c compares presence/absence of exposure knowing the outcome) Use RR for cohort study (know exposure status, then calculate probability of event)"
314
For elective hyst pt with recent cardiac stent what should you do first?
"Find out when/type of stent, wait 12 months, cards/anesthesia consult periop, multidiscplinary If bare metal 90d, if drug eluting 12 months"
315
Femoral triangle
Inguinal ligament, sartorious (lateral), adductor longus (medial), NAVEL from out to in
316
Estrogen receptor expression can help distingish
LMS (40%) vs GIST (none) (THIS ONE), small cell cervix vs endometrial, mucinous ov vs met no, met breast and prim ov (no)
317
Estrogen isoforms created by
Alterantive splicing (THIS ONE), amplification, 2 other choices
318
Esophageal doppler vs. conventional monitoring intraop for fluid resuscitation
"Lower mortality, less ICU stays (THIS ONE), faster return of bowel function, lower MAP, lower CO TL: Less/shorter ICU stay would be my answer. Found association with higher CO."
319
EPO known risks
death (maybe), thrombosis (yes), HTN (yes), QOL better (maybe), less transfusion (yes)
320
Endometrioisis related marker
ARID1A
321
Endometrial cancer mutation associated with good prognosis
Excellent prognosis regardless of grade POLE
322
Elevated CA19-9 and CEA
mucinous tumor
323
EKG changes with HYPERmag
Prolonged QT (same with HYPOMg)
324
EGFR receptor (how it works)
Ligand binding causes dimerization of the transmembrane EGFR receptor which activates the tyrosine kinase domain
325
Effect of multiple variables on survival
Cox proportional hazards model
326
Earliest lab value to measure in nutrition progress
Prealbumin (THIS ONE), albumin, 2 other choices
327
Doxil versus doxorubicin
"Liposomal bound (aka pegylated) witih MPEG methoxypolyethylene glycol to avoid detection by the mononuclear phagocyte system Results in: longer plasma life, reduced volume of distribution, NOT a vesicant and associated with minimal cardiotox, alopecia, nausea/vomiting But increased rates of PPE (dose limiting in 25%) and stomatitis Liposomal bound to IgG, longer duration (THIS ONE), 2 other options"
328
Downstream effect of VEGF receptor binding
Capillary permeability (THIS ONE), increased intratumor pressure, other options
329
Dose of brachy after hyst for endometrial cancer is dosed to where
0.5cm deep and 0.5cm wide
330
Doing an inguinal LND and injury nerve lateral/near the psoas, what will pt not be able to do
Addut thigh, extend knee (this one b/c of femoral nerve injury), abduct thigh, dorsi or plantar flex foot
331
Direct and indirect radiation/xrt mechanisms
"Direct = causes ds DNA break Indirect = free radical which produces oxidative change"
332
Diabetes/HTN med that should be discontinued before CT
Metformin
333
Describe VEGF proteins and receptors
"VEGF A-E and placental growth factor 1-2 VEGF-A,B,E stimulate angiogenesis via VEGFR1 (A/B) and VEGFR2 (A/E) VEGFR-C,D activate VEGFR3 and stimulate lymphangiogenesis"
334
Describe HPV cancer pathway
"E6/E7 are viral oncogene proteins: E6 inactivates p53 leading to its proteosomal degradation, E7 inactivates pRb by competing for binding and then frees transcription factor E2F to transactivate its targets"
335
Define obesity hypoventilation syndrome
PCO2 >45, BMI>30, no other reason for hypercapnea ; HCO3 27 or higher but not diagnostic
336
Deficits from obturator nerve injury
Motor only; loss of adduction (see sheet 2)
337
Deficits from genitofemoral nerve injury
Sensory only; ipsilateral mons and labia majora; sensory of upper anterior thigh
338
Deficits from femoral nerve injury
L2-L4, unable to flex hip or extend knee; knee DTR; sensory anteromedial thigh/leg/foot - aka can't walk
339
Cytokine pro-inflammatory in sepsis
TNF-alpha (this one), IL-2 - note: IL-1 may have some role but TNF-alpha is stronger
340
Cvx cancer 6 mm wide, 2.5 mm deep, CKC with neg margins (question doesn't give LVSI status), wants fertility
Hyst/rad hyst, obs (this one), rad trachelectomy with LND, repeat CKC
341
Criteria for trachelectomy
"1. Desire to preserve fertility 2. Reproductive age 3. Squamous or adeno (i.e., not neuroendocrine) 4. Stage IA1 with LVSI, IA2, or IB1 5. Lesion
342
"Cowden What is the germline mutation? Clinical picture (non-cancer)? Screening?"
"PTEN Clinical picture: GI polyps, thyroid disease, benign breast disease, mucocutaneous lesions Cancer risk: breast, thyroid, endometrial Screening for breast cancer: breast self awareness from 18yo, clinical breast exam q6-12mo from age 25 (or 10 years before earliest family dx), annual MMG from 30-35yo (or 5-10 years before earliest family dx) per NCCN 4/2018 Screening for endometrial cancer: observation and prompt eval of AUB. ""consider annual random EMB +/- US from age 30-35"" per NCCN 4/2018"
343
Cowden most common gyn cancer
Endometrial cancer (lifetime risk 19-28%)
344
Cowden most common cancer
Breast
345
Copy number high (group 4) of endometrial cancer molecular subgroup is most likely what histology?
Serous
346
COPD greatest preop eval risk
O2 sat low
347
Contraindication to radical trachelectomy
LVSI, size 3 cm (this one), adenocarcinoma, multip
348
Contraindication to palliative surgery
DNR, hemodynamic instability (this one), incarcerated hernia, bowel obstruction
349
What histology is a contraindication for radical trachelectomy
Small cell (this one), villous glandular adenoma, mucinous adenocarcinoma
350
Complications of continent conduit
"Leak (5% risk with ileal conduit), perfusion complication (0.5% with ileal conduit), infection (post-op pyelo up to 20% for ileal conduits), stomal stenosis (13% of ileal conduits), parastomal hernia (14%) Stones (5-20%), stricture (10%), metabolic hyperchloremic acidosis b/c resorption of excreted metabolites through intestinal mucosa, B12 def if ileal segment used"
351
Complication of cdiff
Toxic megacolon
352
Colon cancer screening recs
"for Average risk (no history of IBD, no family history) starting at age 50yo (or consider 45yo for African-Americans) per NCCN 4/2018: 1) Colonoscopy q10 years 2) Stool-based test (high-sensitive guaiac-based or immunochemical testing q1yr vs. FIT-DNA-based testing q3yr) 3) flex sig q5years 4) CT colonosgraphy q5years (this replaces barium enema) Least helpful: MD digital rectal exam"
353
What are advanced colon adenomas that increase colon cancer risk
villous or tubulovillous histology, high-grade dysplasia, >/= 1 cm
354
Collateral with obturator artery
Deep external pudendal; INFERIOR EPIGASTRIC - either of these may be answer
355
Chemo for LMS
Gemzar/taxotere (can also do doxorubicin +/- olaratumab per NCCN)
356
Chemo for carcinosarcoma (most efficaceous)
Ifos/taxol - THIS ONE (carbotaxol was not an option), ifoscarbo, cistaxol
357
Changes in apoptosis (two questions)
"not cause inflammation, does cause chromatin condensation 1) cell shrinkage and rounding due to caspase 2) cytoplasm dense and organelles tightly packed 3) chromatin undergoes condensation against the nuclear envelop (PYKNOSIS) 4) nuclear envelope becomes discontinuous and DNA is fragmented (KARYORRHEXIS) 5) cell membrane buds into blebs 6) cell breaks apart into multiple vesicles called apoptotic bodies - these are phagocytosed"
358
Cervical cancer pt s/p RT presents with fever, diarrhea, imaging with collapsed bowel, thick walls, dilated bowel
Thumb printing (thickening of haustral folds) = cdiff due to edema
359
Cancer with elevated CA-125 (ovary not a choice)
Pancreatic (if not breast or lung), breast (THIS ONE per Sjovall 2002 if option, 2nd is lung cancer), colon, gastric
360
Cancer vaccines general mechanism
"Whole cell tumor lysates (?) Tumor-specific antigens needed to stimulate dendritic cells and activate T cells; MHC1 and CD8 cells Three phases of cancer development: elimination, equilibrium (tumor cell variants arise), escape (avoid immune recognition intrinsic mechanisms and extrinsic mechanisms that result in immune suppression in the microenvironment) --> in total- called immune-editing Sipuleucel-T (Provenge) is first therapeutic cancer vaccine for prostate (autologous APCs exposed to cancer antigen, then returned to pt)"
361
Cancer risk with Peutz-Jeghers
Stk11 (tumor suppressor), autosomal dominant - sex cord stromal with annular tubules**, adenoma malignum, stomach (29% by age 65), small bowel (13%), CRC (39%), ovary (21%), cervix (10%), uterus, (9%), breast (32-54%), pancreas (11-36%)
362
Cancer risk with MEN2
Parathyroid hyperplasia (10-25%), medullary thyroid ca (almost all will get this, avg age 30s), pheo (~50% will get this), also get cutaneous lichen amyloidosis & hirschsprung disease
363
Cancer risk with MEN1
"3 P's: pancreatic, parathyroid, pituitary Pancreatic (~30%, Zollinger-Ellison syndrome, insulinoma), pituitary adenoma (15-20%), angiofibroma, parathyroid hyperplasia (almost 100%), lipoma, carcinoid tumors"
364
Cancer risk with Li-Fraumeni
p53 mut - sarcoma (15% by age 70 in women), breast (54%), brain (6%), osteosarcoma (5%)
365
Cancer risk with Cowden
PTEN mut - breast (25-80%, triple neg), endometrial (13-28%), thyroid (3-38%), CRC (9-18%), renal cell carcinoma (2-34%). Also have mucocutaneous lesions (unclear if melanoma is associated or not), thyroid disease (50%), GI polyps
366
Cancer for which smoking is protective
Endometrial cancer
367
Calculator PPV, NPV, sens, specificity
"Sensitivity = true positive rate Specificity = true negative rate PPV = true positive / all positive test NPV = true negatiie / all negative test"
368
Brisk bleeding from deep pelvic LND
Accessory obturator vein
369
Breast cancer screening for BRCA
annual MRI 25-29yo; 30-75yo annual mammo +/- breast MRI/tomosynthesis (NCCN 5/2018)
370
Breast biopsy - atypical ductal cells - what is mgmt?
Lumpectomy to r/o DCIS or cancer, occurs in up to 10-30%
371
BRCA1 most common type of breast cancer
Triple negative, IDC
372
BRCA type of cancer risks
"breast (41-90% lifetime risk), ovary (8-62%), UPSC?, pancreas (1-4.9%), male breast cancer (BRCA2), prostate (BRCA2), uveal melanoma (BRCA2), melanoma (maybe in BRCA2??), stomac/biliary (maybe in BRCA2?)"
373
BRCA 2 - most common type of breast cancer
ductal ER+(THIS ONE), lobular ER+PR+, phyllodes ER+
374
Branches of the internal iliac
"Posterior: ILS (iliolumbar, lateral sacral, superior gluteal) Anterior: Oranges under some ice might peel Obturator, uterine + umbilical, sup ves, inf ves, middle rectal, (int) pudendal, inf gluteal"
375
Branches of SMA
"Inferior pancreaticoduodenal, jejunal branches, ileal branches, ileocolic (->appendicular), right colic, middle colic (see picture sheet 2)"
376
Branches of IMA
Left colic, sigmoid arteries, superior rectal artery (terminal branch)
377
Branches of celiac
Left gastric, common hepatic (proper hepatic, R gastric, R GDA), splenic (dorsal pancreatic, short gastric, L gastroepiploic, greater pancreatic)
378
Brain radiation: which is not a side effect
hair loss, seizures, HA, cerebral hemorrhage (THIS ONE)
379
BRAF
"Serous borderline and recurrent low grade serous carcinoma BRAF and KRAS mutations are mutually exclusive"
380
Bowel injury during L/S no bowel prep, 1 cm, what do you do
Primary repair
381
Blood vessel most likely injured during right diaphragm stripping
Phrenic artery
382
Blood supply to the lesser omentum
Left gastric
383
Blood supply to gracilis flap
Medial circumflex femoral artery
384
Biggest risk factor for LAR leak
"Tension (this one), no bowel prep, only one dose of abx, hand sewn, protective ileostomy Distance of anastomosis from anal verge (if LAR <6cm from anal verge, highest risk i.e., 19% per Morrow) or this one if an option"
385
Best way to quantitate protein
Western blot
386
Best way to check for PE
Spriral CT, CT angiogram (this one), V/Q
387
Best way to amplify DNA
PCR
388
Best test to eval association in case control trial
Odds ratio
389
Best randomization method
Coin flip, random # table blocks (this one), alternate assignments
390
Best med for anticipatory chemo-induced nausea
5HT3, benzos (this one), steroids, other choice
391
Best initial test to start with to evaluate smoking and certain type of cancer
Prospective RCT, case control (good initial study), cohort study, chart review
392
Best initial study to assess relationship between PNV and ovarian cancer
Case control (this one), cohort, meta=analysis, RCT
393
Best imaging for the brain (ie: small cell cancer brain mets)
MRI
394
Best imaging for myometrial invasion in uterine cancer
MRI
395
Best imaging for localizing recurrent cervix
PET/CT
396
Best criteria to diagnose HNPCC
MSI, Amsterdam, MLH1 methylation, MMR gene alterations (this one)
397
Best abx for Klebsiella
"Ceftaz (this one), imipenema and clinda, vanc and gent From emedicine: 3rd gen cephalosporins (i.e. cefotaxime, ceftriaxone), carbapenemas (ie: imipenem), AG (gent), quinolones Consider mono vs dual therapy with the above agents"
398
When p53 is activated - what stage of cell cycle does it arrest?
G1 - or apoptosis if defects are large
399
How do you make monoclonal antibodies?
Fuse myeloma cells with mouse spleen cells immunized with desired antigen
400
What is included in innate immunity?
Present at birth. NK, macrophages, dendritic cells
401
What is included in acquired immunity?
T cells and B cells
402
What is Calvert's formula?
AUC x (GFR + 25)
403
What element is required in RBC production?
Copper
404
Which is not associated with blind loop syndrome?
Overgrowth of bacteria, fat malabosprtion, Fe def, diarrhea, vitamin B12 def (answer: Fe def)
405
How much ileum resection will result in B12 deficiency?
60 cm
406
How much ileum resection will disrupt bile salt/fat malabsorption?
100 cm
407
Oxygen dissociation curve - to the right means what?
Hgb has less affinity for O2 so harer to bind but releases it more readily
408
What causes right shift of oxygen dissociation curve?
CADET - face RIGHT. Increased CO2, acidosis, elevated DPG, exercise, temp.
409
What is a normal TV setting based on weight?
10-15 cc/kg
410
What is a normal A-a gradient?
10-15 mmHg
411
What does PCWP approximate?
LA pressure
412
Are psammoma bodies in high grade serous ovary good or bad?
Good/favorable prognosis
413
Do complete or incomplete moles have villous capillaries present?
"Partial mole have villous capillaries intact - maybe b/c there is a whole fetus there?"
414
Which patients with Bartholin's gland adeno need LND?
All - 20% risk of LN mets
415
How deep laser in non hair bearing?
1 mm
416
How deep laser in hair bearing?
3 mm
417
Which germ cell tumors do NOT need chemo?
Stage I dysgerm, stage I low grade immature
418
What nervse are Klumpke's
C8-T1, claw hand
419
What nerves are Erb's palsy
C5-C6 (can happen from t-burg), cannot lift arm above head
420
What is ipilimuab?
Monoclonal ab for CTL-4 - for melanoma
421
What cells make hCG?
Syncytiotrophoblast
422
What makes up OVA1
CA-125, transthyretin (pre-albumin), Apo A-1, Beta2 microglobulin, transferrin
423
What stain is used for melanoma?
S100
424
Role of LND for vulvar melanoma?
Strictly prognostic, so +/-
425
What are the phases of wound healing?
"Coagulation (mast cells, histamines, fibrin clot, vasoconstriction) Inflammatory response (release of PMNs, macrophages) Fibroplasia (collagen deposition) Remodeling"
426
Tensile strength at 10% for PDS
56 days / 8w
427
Tensile strength at 10% for polyslycolic acid (vicryl)
28 days / 4w
428
Tensile strength at 10% for chromic catgut
14 days / 2w
429
Tensile strength at 10% for catgut
5 days / 1w
430
What is max total local lido w/o epi
300 mg
431
What is max total local lido w/ epi
500 mg
432
What is max mg/kg lido w/o epi
4 mg/kg
433
What is max mg/kg lido w/ epi
7 mg/kg
434
Tx for lidocaine tox
Usual supportive - use benzos for seizures
435
Definition of acute renal failure
Cr > 3x baseline or UOP 0.3 cc/kg/hr for 24h or 12 hours of anuria
436
Causes of hypocalcemia
Hyperphos, tumor lysis, acute pancreatitis, resp alkalosis, sepsis, osteoblastic mets, hypomag
437
Which diuretics may lead to HYPERKALEMIA
Triamterene (K sparing) or spironolactone
438
Which hyperK tx affect serum but not total K levels
Things that push into cells - B2 agonist, glucose/insulin, bicarb
439
Which hyperK tx affect both serum and total K levels
Kayexalate, dialysis, loop or thiazide diuretic
440
What is refeeding
Glu load leads to insulin, cells shift P and K into cells, can lead to life threatening hypoP and hypoK
441
What is pulsus paradoxus and associated with what?
Inspiratory fall in systolic blood pressure >10 mmHg, cardiac tamponade
442
When placing Swan ganz- where are you if you see dicrotic notch
PULMONARY VALVE
443
What cels secrete histamine
Basophils and Mast cells
444
Which cannot transmit CMV?
FFP (b/c no leukocytes)
445
"Which factors are the following Fibrinogen Prothrombin Thrombin"
"Fibrinogen = factor I Prothrombin = factor II Thrombin = factor IIA"
446
PTT
Intrinsic (PITT like pittsburgh)
447
PT
Extrinsic (PET like pets!)
448
Adverse effects from transfusion massive
HYPOcalcemia and alkalosis due to citrate tox
449
How long can you store RBC
42 days (6 wees)
450
What cell do dendritic cells and macrophages come from
Monocytes (myeloid origin)
451
Where are MHC I expressed
Most normal tissue except erythrocytes, plt, trophoblast, germ cells
452
Where are MHC II expressed
APCs, lymphocytes, inflammatory
453
Which cells are MHC restricted vs not
Restrict = T cells, macrophages; Not = natural killer cells, lymphocytes
454
If Swan-ganz will not wedge, what value most closely corresponds?
PA pressure
455
Most common organisms line infection
Coag neg staph, staph auerus, Enterococcus
456
Leading cuase neutropenic sepsis
Gram negative aerobics: ie Pseudomonas, Klebsiella, E coli
457
Tx of SVT
Adenosine
458
29 yo 6 cm cervix cancer, received 10Gy, has right TOA
MRH, BSO, LND (b/c the other ovary is dead)
459
Call Exner bodies
Granulosa cell
460
Schiller-Duval
endodermal sinus tumor
461
Multinucleated giant cells
Dysgerminoma
462
Crockroft-Gault
CrCl = 0.85 for female * (140-age)*(weight kg) / 72*Cr
463
What phase of the cell cycle is most radio-resistant?
Mid to late S and early G1
464
Most radiosensitive?
G2 and M
465
At what energies do certain radiotherapy principles dominate?
"Photo electric effect (below 50 kEv) Compton scattering (100 kEV to 10 MeV) Pair production (greater than 1.02 MeV)"
466
What affects response/sensitivity to radiation? (4 R's)
"Repair (if fractionated, time for recovery of sublethal injury) Repopulation (growth of cells between fractors) Redistribution (depending what part of the cell cycle) Reoxygenation (oxygenated cells are 3x more sensitive to radiation)"
467
Advantage of LET
Does not depend on O2 so effective for hypoxic tumors (oxygen enhancement ratio = 1)
468
What organ is most sensitive to radiation?
Kidney
469
Dose to sterilize ovaries?
1500-2000 cGY
470
How to calculate energy to get to certain depth
Depth in cm x 3 = amount of energy in MeV
471
How to decrease acute effects of radiation
Decrease total dose and treatment time --> affects mucosal cells
472
How to decrease chronic effects of radiation
Decrease DOSE PER FRACTION --> affects endothelial cells
473
What does the shoulder of the cell survival curve represent?
Sublethal damage that is repaired
474
What is the minimum amt of energy to cause ionization?
35 eV
475
Max dose small bowel
45 Gy (that's why dose for cvx is that? And required to sterilize occult dz for adjv radiation)
476
Max dose for bladder and rectum and lower 1/3 vagina
75 Gy
477
"Vaginal cancer - intracavaity alone Add interstitial threshold Add EBRT threshold"
"<5 mm > 5mm > 2 cm"
478
Radiation procttitis
Steroid suppositores, low residue diet, anti-motility drugs, hydration
479
Chronic radiation enteritis
Can try cholestyriamine
480
What radiation particle is decay of radioactive isotope
Gamma rays originate within the nucleus, emitted from radioisotope
481
"What type of radiation is caused by deceleration of high energy electrons?"
X-rays originate outside of nucleus and produced by bombardment of target with high speed electrons
482
Alpha particle
Two protons and two neutrons (i.e. He nucleus)
483
Beta particle
high speed electrons
484
What is Gompertzian tumor browth?
Double time increases as the tumor size increases
485
What shifts the cell survival curve to the left
"Left = less radiation needed Oxygen and higher energy radiation"
486
What is max fetal dose during pregnancy?
10 Gy
487
BRCA1, p53
17
488
BRCA2, Rb
13
489
PTEN
10
490
BRCA1 founder
AG/C (185delAG, 5382insC)
491
BRCA2 founder
T (6174delT)
492
What gene is for the CSF receptor?
Fms
493
Exons most mutated in p53
Exons 5-8
494
Most common p53 mutation?
"Missense (one base chair that alters function) - celll compensates by trying to make more So would have increase in detectable p53 Compared to nonsense mutation where the protein is not made, so absence of p53"
495
Best test to test for HPV?
PCR (this one), not IHC, FISH
496
What is loss of heterozygosity?
"Heterozygosity when you have a mutation in one copy of tumor suppressor gene Can still make tumor suppressor protein With LOSS of heterozygostity, there is a second hit and now both genes are defective"
497
Best test for aneuploidy
Flow cytometry for propidium iodide
498
What does labeling index do?
Measures proliferation and cells that have COMPLETED S phase
499
What does FISH measure?
Hybridize specific base pair sequence then lights up with fluorescence
500
What is the difference with adenoviruses for gene therapy
"Adenoviruses (DNA viruses) not incorporated into host DNA Not replicated when cell divides, so requires re-administration"
501
What is the ?limitation of retroviruses for gene therapy
"Retroviruses (RNA viruses) only infect dividing cells and depend on reverse transcriptive (RNA to DNA) to allow the virus to integrate into the host genome and be continuously produced Disadvantage: this can lead to leukemia"
502
What is ELISA
"Enzyme-linked immunosorent assay Ab bound to plate to capture the antigen; also attached to enzyme that can convert some chemical into something that can be measured by color"
503
What is a Southern blot?
Measures RNA
504
What is a Northern blot?
Measures DNA
505
What secretes IL-1?
Macrophages
506
What does IL-1 do?
"Stimulates Th (cell mediated response) Stimulates maturation of B cells (antibody mediated response or humoral immunity) Macrophages (inflammatory response)"
507
What do dendritic cells do?
Antigen presenting cells
508
How do you make monoclonal antibodies?
Fuse myeloma cells with mouse spleen cells immunized with desired antigen
509
What do natural killer cells do?
"Lymphocyte programs tumor cells and cells infected by viruses Do not require activation (i.e., with MHC1)"
510
First and most sensitive to blood loss?
Pulse/tachycardia
511
What to give if patient has low fibrinogen?
Cryoprecipitate
512
Most common ELECTROLYTE abnormality with TPN
Hypophosphatemia
513
What is malignant hyperthermia?
Reaction to anesthesia, tx with dantrolene, get rhabdo
514
Which are vitamin K dependent coag factors?
II, VII, IX, X
515
OR is closer to RR if prevalence is high or low?
Low
516
What to do if suspect air embolism after Swan Ganz
Left lateral and t-burg, try to aspirate
517
Describe nec fasc
Gray margins, irregular borders, erythema, lymphangitis
518
What is associated with zinc deficiency?
"ALOPECIA, DRY SKIN, growth retardation, decrease taste/smell, depression, impaired wound healing NOT arrhythmia"
519
Where is zinc absorbed?
Small intestine
520
What is associated with selenium deficiency?
CHF, cmo, muscle degeneration, white nailbeds
521
What vitamin is part of glutathione peroxidase?
Selenium
522
Where is copper absorbed?
Stomach and small intenstine
523
What percentage of copper is bound to ceruloplasmin?
0.9
524
What is associated with copper deficiency?
"Anemia, neutropenia, m. weakness, ataxia, depigmentation, neurologic abnormalities NOT bloody diarrhea"
525
What is the Goldman cardic risk index?
For patients undergoing non-cardiac surgery cardiac risk factors to predict perioperative M&M
526
What is the risk of reinfarction <3 months and >6 months after MI?
30%; then 1-2%
527
What abx for high risk endocarditis undergoing dental procedure?
Amp
528
What abx for high risk endocarditis undergoing abdominal surg?
None!!
529
Ideal time to stop smoking before surgery?
4 weeks
530
Which does not cause an increased A-a gradient?
Shunting, V/Q mismatch, hypoventilation (this one)
531
What is the diff between AC/IMV/PC ventilation?
"AC = assist control Triggered with patient's resp effort but if not intiiated will deliver a breat at pre-specified interval, patient can overbreathe the vent IMV = intermittent mandatory ventilation Initiates breath at prespecified intervals if patient doesn't (but not triggered by ptatient breath), problem can have increased work of breathing"
532
What is the relationship between adjusted PCWP and ARDS vs CHF
"Adjusted PCWP < 44 mmHg below colloid oncotic pressure - likely ARDS Adjusted PCWP > 44 mmHg above colloid oncotic pressure - likely CHF"
533
What is the goal of phase I, II, III, IV trials?
"I = max tolerated dose II = biologic activity III = usually RCT IV = large scale to see if can translate to larger population"
534
What is the relationship between SD and variance
SD is square root of variance
535
What is smsaller than the SD? How do you calculate it?
SEM (standard error of the mean) = SD / square root of n
536
Doing multiple t-tests results in more of what type of error?
Type I
537
Is chi-square parametric or non-parametric?
Non-parametric
538
Which is worse - micropapillary or microinvasion in borderline tumors?
micropapillary
539
What is pathognomic for endodermal sinus tumors?
Schiller duval bodies
540
What % of benign teratomas contain thyroid tissue?
0.1
541
What % of struma ovarii are malignant?
0.1
542
PvLN mets - cervix cancer
"stage IA1 - 1% any stage IA2 - 7% any stage IB - 15% stage II - 25-45% stage III - 45-60%"
543
PaLN mets - cervix cancer
"stage IB - 5% stage II - 15-20% stage III - 30% stage IV - 30%"
544
DES exposure - breast cancer risk
increased
545
DES exposure for CHILDREN - how much higher risk vaginal clear cell?
40x (the MOTHERS do not have any increased risk)
546
Do complete or incomplete moles have villous capillaries present?
"Partial mole have villous capillaries intact - maybe b/c there is a whole fetus there?"
547
Which is not associated with GTD risk
"Extremes of age, prior mole, low beta carotene, low fat, NLRP7 gene mut, Asian High animal fat intake (this one)"
548
Basis of grading for immature teratoma?
Amount of neuroepithelium
549
What % dysgerminomas are bilateral?
10-15%
550
How often hair bearing areas involved with VIN?
0.5
551
What is the sensitiity of mammogram?
80-90%
552
What is the specificity of mammogram?
0.94
553
What % breast cancers are Her2+?
0.2
554
What % breast cancers are triple negative?
0.15
555
Which germ cell tumors do NOT need chemo?
Stage I dysgerm, stage I low grade immature
556
What is dose of EBRT for breast cancer
50Gy, if adj 10-15 Gy
557
What nerves are brachial plexus injury
C5-T1
558
Vemurafenib or dabrafenib to tx who/what?
Melanoma BRAF mutations
559
What cells make hCG?
Syncytiotrophoblast
560
What makes up OVA1
CA-125, transthyretin (pre-albumin), Apo A-1, Beta2 microglobulin, transferrin
561
What tumor marker is elevated for PSTT
HPL
562
Where is Breslow's depth measured from for melanoma?
From granular layer of surface epithelium
563
What are the levels of Clark
"Level 1 = in situ Level 2 = through BM Level 3 = through papillary dermis Level 4 = through reticular dermis (survival starts to drop off from 90% or higher to 67%) Level 5 = through subcutaneous fat (33%)"
564
What are the levels of Breslow
"Level 1 = 0.75mm Level 2 = 0.75-1.5mm Level 3 = 1.5-4mm Level 4 = > 4mm"
565
Where does the splenic artery run in relation to pancreas?
Superior to pancreas
566
What % is pancreas within 1 cm of splenic hilum
75% - so be careful
567
"For transureteroureterostomy - where should it run in relation to IMA and great vessels"
In front of great vessels can be in front of or behind IMA
568
"What is the 10 year and lifetime risk of sepsis in a patient who has undergone splenectomy"
"5-year risk of sepsis: 7% Lifetime risk of sepsis: 25%"
569
How often should spleenctomy patients get vaccinated?
Every 5 years
570
Which invade first PMNs or macrophages?
PMNs
571
Least important consideration for refluex in continent conduit
Ileal length -detubularizing eliminates peristalsis, longer colon segment = more capacity, ureteral insertion impt
572
Is dialysis useful for lidocaine overdose
No
573
Tx for lidocaine tox
Usual supportive - use benzos for seizures
574
How to calculate SVR
(MAP-CVP)/CO (SV x HR)
575
Most common abnormality in DIC
D-dimer elevation
576
Indications for dialysis
"Uncontrolled hyperkalemia, acidosis, vol overload, uremic sx (i.e., pericarditis, neuropathy, AMS, coagulopathy)"
577
Sx of hypercalcemia
Stones, bones, groans, psych overtones
578
Most common cause of hypercalcemia
HyperPTH
579
What drugs cause hypocalcemia
AG, cimetidine, heparin, theophylline
580
Calcium correction for albumin
For every 1 mg/dl decrease in albumin, increase calcium level by 0.8
581
Most abundant electrolyte in body?
Ca (bones!)
582
Most abundant extracellular cation
Na
583
Most abundant intracellular cation
K
584
What electrolyte issues can you give lasix (loop diuretic)
HyperK and HyperMg
585
What drugs cause hypoMg
AG, dig, cisplatin, loop diuretics, thiazide diuretics
586
Which diuretics may lead to HYPERKALEMIA
Triamterene (K sparing) or spironolactone
587
Which hyperK tx affect serum but not total K levels
Things that push into cells - B2 agonist, glucose/insulin, bicarb
588
Which hyperK tx affect both serum and total K levels
Kayexalate, dialysis, loop or thiazide diuretic
589
Sx of hypokalemia
Weakness, decreased DTR, mental status change, ileus, cardiac issues
590
Which is not a tx for short bowel syndrome?
Agents to slow intestines, nutritional support, octreotide (this one - b/c stomach), B12
591
What changes occur with short bowel syndrome to intestinal villi
Hypertrophy
592
Essential fatty acids
Omega 6 (linoleic acid) and Ometa 3 (alpha-linoleic acid)
593
What is the half life of pre-albumin
3 days
594
What is the half life of albumin
20 days / 3w
595
Calorie requirement based on weight for TPN
30 kcal/kg/day
596
Types of nec fasc I and II
"Type I: aneaerobic/aerobic Type II: group A strep or other beta emolytic strep +/- staph aureus"
597
Hyponatremia correction rate to avoid wha tcomplication
9 meQ/L/24h to avoid central pontine myelinolysis
598
Which is least likely to affect A-a gradient
ARDS, hypovent (this one), PNA, pulm edema, PE
599
Electrolyte abnormalities for hypoaldosteronism
Low Na, High K
600
Tx for HYPOaldosteronism
Steroids
601
Tx for HYPERaldosteronism
Sprionolactone
602
Main electrolyte abnromalities for HYPERaldosteronism
Low K
603
Best predictor of weaning off vent
Rapid shallow breathing index (RR/TV); good if RSBI <105
604
What is contraindication to PA catheter placement
LBBB
605
What is measure of preload
PCWP
606
What is measure of afterload
SVR
607
What is the enzyme assoc with COPD
alpha-1-trypsin
608
Adverse effects from transfusion massive
HYPOcalcemia and alkalosis due to citrate tox
609
How long can you store RBC
42 days (6 wees)
610
What do CD4 cells do
B cell differentiation, CD8 proliferation, cytotoxic effector cells, recognitize MHC II
611
What do CD8 cells do
Suppress antibody synthesis, act as cytotoxic effector cells, recognize MHC1
612
"Immunoglobulin function A, D, E, G, M"
"A = first response D = directs macrophages, dendritic cells E = allergy G = 2nd line Ab M = 1st line Ab"
613
Null cells that don't express cell surface antigens
i.e., lymphocytes i.e., NK cells
614
Which cells are MHC restricted vs not
Restrict = T cells, macrophages; Not = natural killer cells, lymphocytes
615
What is a potent stimulator of T cells
IL-2
616
Where is ERBB2 (aka Her2) primarily expressed
Epithelial cells
617
Where is EGFR expressed
Epithelial and stromal cells
618
Another name for lesser omentum
Gastrohepatic ligament
619
What is the portal triad and what is it enclosed by
Bile duct, hepatic a, portal v, encased by hepatoduodenal ligament
620
"What supplies the sartorious muscle? And tensor fascia lata"
LATERAL femoral circumflex (v. medial for the gracilis)
621
What separates the subclavian artery and vein?
Anterior scalene muscle
622
What is the venous drainage above and below the pectineate line?
internal iliac above, superficial inguinal LN below
623
What is epo production stimulated by?
Decreased O2 in the renal artery
624
If Swan-ganz will not wedge, what value most closely corresponds?
PA pressure
625
ABG for PE
Alkalotic (tachypneach), decreased CO2 and PaO2; elevated A-a gradient
626
Malnutrition definition
Progressive weight loss >10% of desired body weight for age/sex
627
Most common injury L/S
Bowel
628
Nerves that are MOTOR and SENSORY
Pudendal, obturator, femoral
629
What GTD is more important for hyst
PSTT since chemoresistant
630
Tamox least likely to be associated with what benign
Hyperplasia wihtout atypia > Endometrial polyps > Endometriosis > Ovarian cysts > Fibroids
631
Average doubling time of tumors
50 days
632
What subunit of HCG is shared with other hormones
Alpha same as LH, FSH, TSH; beta is distinct
633
Innervation fo bladder
S2-S4, parasympathetic - inferior hypogastric plexus, sympathetic - superior hypogastric pleux
634
Type of bladder malfunction after radhyst
Neurogenic (retention)
635
What nodes do cervical cancer drain to first?
Internal iliac nodes
636
Most common tumor in dysgenetic gonads
Gonadoblastoma (benign)
637
Most common malignant tumor in dysgenetic gonads
Dysgerminoma
638
Tamoxifen vs. raloxifene
"Both anti-est in breast (tamox stronger than raloxifene, but raloxifene less risk VTE) Tamox pro-est in endometrium, but raloxifene is not Both pro-est in the bone"
639
1 mg tumor = how many cells
10^6
640
1 cubic cm tumor = how many cells
10^9
641
What are static cells?
Well-differentiated that rarely undergo division as adults (ie neurons, oocytes, striated m, nephrons
642
What are expanding cells?
Normally quiescent but grow under stress/injury (ie hepatocytes, vascular endothelium
643
What are renewing cells
Constantly replicating (ie BM, epidermis, GI
644
First order cell kill kinetics
Constant FRACTION of cells killed with each treatment
645
To achieve "cure" how many tumor cells left
10-10K
646
What is Goldi-Coldman hypothesis?
"Mutation towards drug resistance occurs spontaneously at a rate of 1 mut/million cell divisions or more Thus, as mass increases, likelihood of spontaneous mutation increases and drug exposure further increases mutations"
647
What are the boundarie of the inguinal triangle
Rectus muscle, inferior epigastric artery, inguinal ligament
648
BRCA prevalence in Ashkenazi Jews
BRCA1 1.5%, BRCA2 1%
649
Mechanism of apoptosis (3 phases)
initiation, effector, degradation
650
Which is least emetogenic? Carbo, vinca, doxorubicin
Vincas
651
Which chemo is activated within a tumor cell?
Xeloda
652
When is LET best used?
necrotic tumor
653
IMRT differs from 4-field radiation in all ways except:
Delivers same dose
654
Most common side effect of whole pelvic XRT
ileum (this one), rectum, bladder, ureter
655
Which has highest LET?
alpha particle > neutron
656
Which does not come off the femoral nerve?
Deep circumflex (this one), superficial circumflex, external pudendal
657
What ligaments taken down for liver mobilization?
falciform, coronary, right triangular ligament
658
During inguinal LND, use of fibrin sealants increases risk of?
Infection (this one), drainage from site, wound separation
659
Most common complication after splenectomy?
Transient bacteremia with encapsulated organisms (This one), left atelectasis, abscess, pancreatic leak
660
Antibiotic to cause Achilles tendon rupture
Cipro
661
Antibiotic that causes pulmonary fibrosis
Macrobid
662
Medicine class most associated with delirium in elderly post-operative patients?
Benzos (This one), anticholinergics
663
What is least likely complication of premenopausal BSO?
Kidney stones (This one), anxiety/depression, CV dz, metabolic syndrome
664
What differentiates LMS from undifferentiated uterine sarcoma?
Cytologic atypia to the extent that they cannot recognize as arising from endometrial stroma
665
18yo with adnexal mass, alpha antitrypsin 1 staining?
Yolk sac tumor
666
Most predictive of postoperative cardiac performance?
Dobutamine stress test
667
What electrolyte abnormalities from massive transfusion?
HyperK, HypoCa
668
Ideal ROC curve AUC
Higher AUC, the more accurate
669
Difference in number of people who get a disease exposed to a risk minus people with a disease not exposed to a risk
Attributable risk (this one), absolute risk, risk difference
670
Which growth factors bind to serine-threonine kinase receptor?
Peptide growth factors
671
was there a difference in QOL during or after IP therapy
worse during and 6 weeks after
672
70 yo with DM, HTN, AFIB sp TLH/BSO what anti caog post op
lovenox
673
which is a watershed area
splenic flexure
674
what is a non specific immune modulator
interferon
675
MOA of ipilmumam
CTLA4
676
WHAT AFFECTS SAMPLE SIZE IN CLINICAL STUDIES
confidence interval
677
What affects HDR
applicator, distance and source
678
what opiate causes prolonged QT and torsades
methadone
679
what makes a tumor antigen a good immune target
expression on sell surface
680
what happens with trendelenburg and pneumoperitoneum
increase in CVP, PCRP, SVR, MAP and decrease in CO
681
New questions from 2019:
Answer
682
Which of 4 PARP inhibitors is most likely to cause rise in LFTs/transaminitis?
Choices: Olaparib, Niraparib, Rucaparib, Velaparib
683
What side effect is most likely with Gemcitabine?
?Thrombocytopenia... can't remember the other choices
684
Marker/stain for Paget's disease of CUTANEOUS origin
"Choices: S100, Melan-A, HMB45 and others I can't remember. Per lit search: Primary intra-epidermal Paget disease is GCDFP-15 positive, CK7 positive, and CK20 negative. Primary vulvar Pagets (ie: cutaneous) expresses CK7, GCDFP and CEA but NOT CDX2, S100, HMB45, ER or PR. Secondary vulvar Paget disease most commonly represents spread of urinary tract (CK20+, uroplakin+, thrombomodulin+) or colorectal adenocarcinoma (CK20+, CDX2+, CEA+). In contrast, cutaneous melanoma is Melan-A positive, S100 positive, and HMB45 positive."
685
FOXL2 is associated with which type of tumor?
Adult granulosa cell tumor
686
BRCA1 associated breast cancer is most likely to have what histology?
"Choices: Basal-like (this one), HER2 pos, Luminal A, Luminal B Per lit search: BRCA1 breast cancers are triple negative and basal-like. BRCA2 breast cancers are luminal B type."
687
Bleomycin active in which stage of cell cycle?
Choices: G1, G2, S, M
688
Cobalt-60 emits what?
Choices: Electrons, photons, …..??
689
How do you treat vesicant extravasation in tissue?
Choices: Tylenol, dimethyl sulfoxide (listed twice as answer choices B and D.. nice) and Dexrazoxane/aka Zinecard
690
Type 1 endometrial cancers are associated with what?
Choices: IGF1, FGF, other options…
691
Increased insulin leads to increased risk of EMCA how?
Choices: decreased IGF1 receptors, decreased IGFBP1, increased progesterone receptors and other options
692
Intermittent/alternate use of Tamoxifen with progesterone to tx EMCA works by:
"Choices: increasing progesterone receptors (this one), increasing E2 receptors, and other options Per lit search: Tamoxifen, acting through ER, is thought to increase expression of PR, and thus sensitivity to medroxyprogesterone acetate."
693
Not adequately treating a patient's pain goes against what principle?
Nonmaleficence
694
What can you do to decrease skin damage from XRT to vulva?
Choices: topical E2 cream, application of cold packs, open leg positioning, and 1-2 other choices
695
CA19-9 is most associated with what?
Mucinous CRC, pancreatic cancer, breast cancer, and 1-2 other options
696
What is best lab test in setting of a suspected myocardial infarction?
I chose Troponin... can't remember other choices
697
What is best treatment for recurrent low grade ESS with mass fixed to pelvic sidewall?
Choices: radiation, megace, a few cytotoxic chemotherapeutics
698
Mechanism of tumor evasion of immune system?
I have no idea what I put.
699
What type of virus is HPV?
"Chocies: Single strand RNA, single strand DNA, double strand DNA (this one), single strand DNA HPV is a small double-stranded circular DNA virus"
700
What does "restrictive" intraoperative fluid resuscitation do?
"Choices: decrease mortality, increase hospital stay, decrease postop complications, and other choice Uptodate: ""Standard"" fluid replacement associated with higher risk for pneumonia, pulmonary edema, as well as longer hospital stay when compared with a ""restrictive"" approach. Although, a restrictive (zero-balance) fluid regimen was associated with a higher rate of acute kidney injury (AKI) compared with a liberal fluid regimen."
701
Pregnant patient has a 3cm palpable breast nodule, what should you do?
Choices: observe, mammo, ultrasound, biopsy (this one!)
702
Young patient with new dx grade 1 EMCA, wants to preserve fertility. What should you do next?
Choices: Pelvic MRI, CT (I chose this), Ultrasound, Saline-infused hysterosonogram
703
What vessel are you likely to get bleeding from during anterior mobilization of the liver?
Choices: hepatic vessels, portal vein, and others
704
"Flaps: 2 questions about lowest failure in vulvar reconstruction surgery One question was: small vulvar defect after radical vulvectomy which flap is best (least likely to fail) - rhomboid, singapore, gracilis or another option"
Choices included: TRAM, gracilis, V-Y, Singapore, Rhomboid
705
Most direct mTOR inhibitor? (mTOR inhibitors like everolimus were not one of the answer choices)
Choices: Gleevec, metformin, parp, pertuzumab and one other...
706
Most sensitive cell type to whole pelvic XRT?
Choices: Erythrocytes, granulocytes, lymphocytes, megakaryocytes
707
?Definition of Haylick principle in radiation?
708
Which pelvic tumor is most associated with prior pelvic radiation?
Carcinosarcoma
709
Which cancer is most commonly associated with prior radiation?
Leukemia
710
After attempted insufflation with a Veress needle, an air embolus is suspected. What should you do first?
Answer = Steep trendelenburg; Choices: Steep trendeleburg, R lateral positioning, exploratory laparotomy, administer nitrous oxide
711
What vitamin deficiency is most likely after a right hemicolectomy?
Choices: Iron, B12, Folate, Calcium, and 1 other
712
What is standard error of the mean (SEM)?
Answer choices did not ask for calculation, but had descriptions of what it measures and how it relates to SD.
713
SE of pazopanib
714
POLE group most likely to be which TCGA category
ultramutated
715
Pharmacokinetic profile of doxorubicin is most likely due to...
Choices: protein binding, biliary excretion, 2 other choices
716
on PARP with recurrent ovary and now has rising Cr - most likely due to..
Choices: ureteral obstruction, CYP induction, some other thing I have never heard of
rucaparib inhibits the drug transporters MATE1 and MATE2-K, which play a role in renal secretion of creatinine
717
how does PD-1/PD-L1 interaction work
718
mechanism of lung injury from TRALI
Choices: cytokines, leukotrienes, can't remember the other answers
719
most common cause of mortality from massive transfusion
TRALI, TACO, ABO incompatibility, non-ABO incompatibility, and another choice
720
lady with 5cm IB2 SCC of cervix, reason that cis/RT would be contraindicated
Choices: pelvic kidney, irritable bowel syndrome, morbid obesity, one other choice
721
Most inotropic pressor
Dobutamine
722
Dopamine effect at intermediate dose (3-7.5)
increase CO by acting on cardiac and peripheral circulation
723
Young woman with low-risk GTN - failed mtx, switch to what regimen?
Pulsed Act D (THIS ONE bc low risk), EMACO (would be this one if high-risk)
724
WHO score - what has greatest impact: ie the one worth 4 points
Choices: 6cm tumor, hcg 100k, term pregnancy, interval months from index pregnancy 7 months, Liver met
725
Which opioid has the longest half life
Methadone
726
"Which is not a gap acidosis? Know mnemonic for anion gap metabolic acidosis"
"RTA (and diarrhea), pancreatic leak, and spironolactone cause non-gap acidosis Rhabdo causes increased anion gap acidosis! MUDPILES methanol uric acid (aka uremia/ARF) DKA paraldehyade, phenformin iron, INH lactic acidosis ethylene glycol salicylates"
727
Which drug is a vesicant
"Vinca List of ones I care about from uptodate: A D M V Y (actD, doxorubicin, mitomycin, vinca, yondelis/trabectedin)"
728
Which chemo do or don't you have to renally dose (**Multiple questions**)
"Cytoxan (def no), topo (def yes), gem (time if on HRD), methotrexate (def yes) A BICC THEM (ones to renally dose) Act D, bleo, ifos, cis/carbo, cytoxan, capcitabine, topotecan, hydroxyurea, etoposide, mtx/pemetrexed"
729
Which chemo are pro-drugs
Capecitabine, ifosfamide, cyclophosphamide, 5-FU, gemcitabine
730
Where does the SMV drain
Portal v
731
Where does the IMV drain
Splenic v to portal v
732
Where does external pudendal come from
Femoral artery
733
Where are estrogen receptors most often located?
Cytosol initially once activated by estrogen, move into nucleus; I think nucleus is the answer bc it's a "nuclear" receptor
734
when would you use a one tailed versus a two tailed
When the alternative hypothesis can only go in one direction (rather than two)
735
What is the other name for the protein CA125
MUC16 or mucin16
736
What is the function of iressa? (generic: gefitinib)
EGFR inhibitor
737
What is the advantage of protons over electrons in radiation
"Dose stops at precise place due to Bragg peak (electrons are less precise; most of the dose is delivered 0.5-3 cm from patient's skin and then gradually loses energy until reaches its target; affectingn the non-target tissues) Question answer choices: increased dose at desired depth, less scatter, less skin damage, and 1-2 others"
738
What is methylation
"epigenetic change (methylation of cytosine residues residing next to guanine residues CpG dinucleotides, methylation silences gene expression) not a SNP"
739
What is high LET radiation?
"High LET = alpha, neutrons (**2 separate questions. 1 asked for which had HIGHEST LET - choices: Pimeson, alpha (this one), neutron, proton; 2nd asked which is high LET: answer was neutrons bc alpha wasn't a choice) Low LET = electrons, gamma rays and x-rays (both electromagnetic radiation)"
740
Which has highest LET?
alpha particle > neutron
741
What is % dose of XRT 1 cm vs 2 cm from source?
400%; b/c dose ~ 1/r squared (1/1 vs 1/4)
742
What has been associated with decreased infection in groin dissection?
Saphenous vein sparing
743
What happens with TP53 mutation
Mutated p53 bind to wild-type p53 and inactivate them (this one = answer), directly impair DNA, and other choices (p53 activate s DNA repair proteins after DNA damage, arrest at G1/S after DNA damage, can initiate apoptosis)
744
What gives off the right gastroepiploic artery
Gastroduodenal artery
745
What does ROC curve measure?
"Optimal is upper left corner where false positive rate is 0 and true positive rate is 1 Diagonal through the center represents ""random"" so if above it, ""better than random"" x-axis = False positive rate (or 1-specificity) and y-axis = True positive rate (or sensitivity) (ROC) curve the true positive rate (Sensitivity) is plotted in function of the false positive rate (100-Specificity) for different cut-off points. Each point on the ROC curve represents a sensitivity/specificity pair corresponding to a particular decision threshold. A test with perfect discrimination (no overlap in the two distributions) has a ROC curve that passes through the upper left corner (100% sensitivity, 100% specificity). Therefore the closer the ROC curve is to the upper left corner, the higher the overall accuracy of the test."
746
What distinguishes PSTT from choriocarcinoma
PSTT: INTERMEDIATE trophoblasts, HPL and lower hCG **Both have NO VILLI.
747
What chemo most asscoiated with constipation
Vincristine
748
What chemo is primarily renally cleared?
Bleomycin (**Bleo more renally cleared than etoposide; both were possible choices)
749
Vulvar cancer: 1 cm vulvar cancer, 2 pos LN in right groin, what is postop adj mgmt?
Bilateral groin XRT, groin + pelvic XRT (this one), other choices
750
Vulvar cancer staging: 1 question - vulvar lesion with two 6mm LN pos
IIIB
751
Vessels encountered during inguinal LND
"Vessels encountered: Femoral artery, superficial circumflex (lateral), superficial external pudendal (medial, **This one was the answer, no other possible choices were in this area), superficial epigastric (superior), -- and saphenous vein Answer is which is not: deep circumflex femoral"
752
Type I error
Erronerously rejects null hypothesis (like false positive) - this is sort of worse; alpha (ype I error is to falsely infer the existence of something that is not there, while a type II error is to falsely infer the absence of something that is.)
753
Tx of HYPERmagnesemia
Fluids and loop diuretic (i.e., lasix) this one; other options included calcium, and other rchoices
754
Treatment of cystitis during xrt
Oxybutinin (anti-cholinergic, antagonizes M1, M2, M3 receptors of Ach receptor), if chronic then observe
755
Timing of splenectomy vaccination
At least 14d before, otherwise 14d after (not sooner!)
756
Target for areprepitant
NK1 receptor (located centrally and peripherally); dominant ligand is substance P
757
Survival analysis for multiple variables
Answer: Cox proportional hazard; (Cox prop hazard evaluates survival using both categorical and quantitative variables and can be used with 1 or more variables. Kaplan Meier curves and log rank test are both UNIVARIATE and evaluate categorical variables only.
758
Statistical test used for evaluation of independent variables
Logistic regression
759
Statistical test for comparing the means of 3 variables
ANOVA
760
Statistical analysis for before and after intervention in same subjects (i.e., BP readings)
Paired t-test
761
Staining if ovarian met from colon
CK7 neg, C20 pos for colon cancer whereas ovary CK7 pos, CK20 neg
762
Staging for endometrial cancer - presence of superficial cervical glandular involvment, positive cytology, 40% myometrial invasion, no extrauerine metastasis: choices IA, IB, II, IIIA
Stage IA
763
Stage I endodermal sinus tumor @ 18 weeks s/p surgery. Best step now?
Immediate chemo (3-4 cycles BEP)
764
Specific mechanism of action for bev
Inhibints VEGF-A it directly binds it (NOT THE RECEPTOR!!!!!)
765
Screening for HNPCC; Answer choice involved EGD
"CRC (50-80% risk) - colonoscopy between ages 20-25 or 2-5 years before youngest dx in family, every 1-2 yrs Endom (16-60% risk) - no definite evidence of EMBx or US; can consider TAH/BSO after childbearing Stomach/small bowel- EGD every 3-5 years starting age 30-35 for certain (i..e, Asian, MLH1, MSH2, EPCAM), H.pylor testing/treating Urothelial- consider annual UA (i.e., MLH1, MSH2, EPCAM) Pancreatic- none CNS- none"
766
Route/course of femoral nerve **TWO questions**
From posterior the posoas and emerges at lower part of lateral border, between psoas and iliacus muscle, beneath inguinal ligament under the intuinal ligament (femoral triangle). Femoral nerve arises from L2-L4 posterior cords (versus obturator n which arises from L2-L4 anterior cords and emerges from medial border of psoas muscle).
767
Risks factors for GTD
"age <20 (this one), blood type O, two other choices From lit: extremes maternal age, OB hx prior molar pregnancy or SAB, diet low in animal fat/carotene/vitA, blood type A or AB"
768
Pt with elevated serum hCG no other signs of GTD, what is next step?
"uPT (to r/o phantom hCG - this one), repeat serum hCG, free hcG, other option due to heterophilic Ab which are not excreted in the urine **My question asked which set of labs is consistent with heterophile antibody/no pregnancy: answer = neg UPT/pos serum hcg."
769
Pt on tam x 2 years, 8 weeks pregnant: what do you recommend
termination, d/c tam for pregnancy and breast feeding (I think this one?), continue tam; class D - d/c for pregnancy and breast feeding
770
PPV affected by what
"Prevalence (whereas, likelihood ratios do not depend on prevalence) Higher prevalence will increase PPV and decrease NPV; no impact on sensitivity or specificity"
771
Postop pt VSS and afib: answer choices beta adrenergic blocker, anticoagulation, digoxin, 1 other choirce
beta blocker = answer; not anticoagulation since immediately postop and new-onset. Rate control almost always first choice in any case.
772
"Peutz Jeghers What is the clinical picture? What cancers are they at risk for? What screening test is not needed?"
"Clinical picture: GI polyps, pigmented lesions on lips/mouth Cancer risk: GI and breast cancer Gyn issues: SCTAT (sex cord stromal tumors with annnular tubules of ovary) and adenoma malignum of the cervix Colonoscopy, pap smears, ultrasound, EMB (THIS ONE), breast imaging **My question asked which inherited syndrome is most associated with adenoma malignum of the cervix (answer: Peutz Jeghers)"
773
PEEP and ARDS
high peep strategy: PEEP 10-15 most important variable
774
Partial (vs complete) mole
"PARTLY paternal, triploid, fetus often present, focal edema (rather than diffuse), rare med complications, SGA, <5% malignant sequelae **My question asked which is most consistent with a partial mole? Answer choices: diploid (no), diandric (this is what i chose?), absence of fetus (no), increased risk of malig sequelae (no)"
775
PARP inhibitor mechanism
Causes ss dna breaks that can't be repaired by BRCA defective cells; blocks base excision repair (BER), which is responsible for ss DNA break repair; these are converted to ds DNA breaks, which cannot be repaired by patients with hemologous recombination deficiency (HRD/BRCA mutation)
776
p53 mutation
"deactivates proteins (??) DNA-binding ability of mutant p53 or changes in interaction of mutant p53 with proteins (esp transcription factors) or other proteins normal activity of p53- binds to transcriptional regulatory elements of genes that act to arrest cells in G1 cancer often have missense mutations in 1 copy of TP53 gene does NOT require inactivation of both TP53 alleles if a MISSENSE mutation, bc it acts in ""dominant negative"" fashion b/c if cancer cell has one normal TP53, the mutant forms complex with normal p53 to prevent it from oligimerizing and interacting with DNA; results in increased intracellular accumulation of p53 and increased p53 IHC staining!! inhibits proliferation also stimulates apoptosis cells that have excessive genetic damage ""guardian of the genome"" bc delays entry into S phase until genome has been cleansed of mutations"
777
Origin of middle rectal artery
Internal iliac, anterior division
778
Old lady died after unvaccinated and splenectomy (which organism is most likely to be cause of her death?)
Encapsulated organisms: Mengigococcus, H. flu, Strep pneumo* (answer choices included all 3.. grrrr: Hflu, strep pneumo, neisseria meningitis, and other non-encapsulated bugs)
779
Non-epithelial ovarian cancer that sometimes needs secondary cytoreduction
"Immature teratoma (THIS ONE), MMMT Cases where pt received adj chemo for immature teratoma and have bulky residual even w/ normaliztion of negtive markers; reasonable to do surgery; sometimes path during secondary debulk with not be malignant then observe, if malignant viable tissue then addtll chemo"
780
Most reliable way to confirm endotracheal tube is in correct position
Distance, pCO2, O2 sat, mmHg (answer = end tital CO2 40 mmHg)
781
Most likely to be associated with lymphatic spread
"Adenosarcoma, MMMT (this one), uLMS, undiff sarcoma **My choices were: granulosa cell tumor, UPSC, mucinous carcinoma, uLMS; Dysgerminoma and MMMT were not options)"
782
Most lethal impact of radiation
Double strand break; other options: single strand break, 2 other choices
783
Most emetogenic
"High risk = Anthracycline (ie. Doxorubicin), cyclophosphamide (or ifosfamide) Moderate risk = Carbo AUC >4, cis, Actinomycin D, Vincas"
784
Most diagnostic of ARDS
Bilateral pulm infiltrates, Pa/FiO2 ratio <200 (this one), two other choices
785
Most common reason for hyperkalemia postop
renal dysfunction
786
Most common germline ov ca mutation
p53, BRCA 1 (THIS ONE), BRCA 2
787
Most common electrolyte disturbance from urinary diversion **2 questions**
Excess chloride (absorption of excreted metabolites through intestinal mucosa); leads to metaboilc acidosis
788
Most common cuase of ilioinguinal nerve injury
Transverse incision (this one), retractor, hyperflexion
789
Most common complication of HIT
Thrombosis (this one), hypersplenism, ARF
790
Most common complication continent ileal conduit compared to incontinent conduit?
"Can't cath aka stomal stricture (2-14%, this one), leaking (short term 2-10%), stone formation (3% upper tract, 5-35% pouch calculi) infection early 1-13%, late 3-10% TL: Lit search suggests the answer is stricture Stricture/cath issues was NOT an answer choice... Choices included anastomotic leak (I chose this one?), pyelo, renal failure, and 1-2 others."
791
Most common cause of prolonged metabolic alkalosis?
"Sheet says: NG tube two most common causes of metabolic alkalosis in general are loss of gastric acid (vomiting, NG drainage) and diuretics (specifically furosemide and thiazides)"
792
MicroRNA when bind to 3UTP region - targeted mechanism of action
"inhibit transcription microRNA = small non-coding RNA that functions in RNA silences and post-transcriptional regulation of gene expression silencing? TL: ""Gene silencing may occur either via mRNA degradation or preventing mRNA from being translated. For example, miR16 contains a sequence complementary to the AU-rich element found in the 3'UTR of many unstable mRNAs, such as TNF alpha or GM-CSF.[87] It has been demonstrated that given complete complementarity between the miRNA and target mRNA sequence, Ago2 can cleave the mRNA and lead to direct mRNA degradation. Absent complementarity, silencing is achieved by preventing translation."""
793
Mechanism of cisplatin with radiation
"Cell repair inhibited, inhibits repair of sublethal damage Mechiansm of action: binding with DNA causing INTRAstand cross-links and DNA adducts"
794
Mechanism of action: topotecan
Inhibit TOPO-I (a nuclear enzyme that relieves torsional strain in DNA by opening single strand breaks); forms stabilized ternary topotecan-TOPO-I-DNA complex with replication enzymes which results in dsDNA breaks and cellular death
795
Mechanism of action: etoposide
"Inhibits TOPO-II enzymes (does NOT bind directly to DNA rather stabilizes transition form of DNA-TOPII / by stabilizing this it ""poisons"" TOPOII enzymes which usually helps cells progress out of G2"
796
Main differences between HDR and LDR
"LDR is 0.4-2.0 Gy per hour vs HDR is >12 Gy per hour More fractions and dose for HDR - perhaps ""better tumor control"" b/c less time for tumor to repair, but studies equivocol; overall LESS TX TIME PER FRACTION Less fractions and dose for LDR - better tissue repair esp for ""late responding tissues"" LDR where radioactive source positioned inside for a few days vs HDR remporary placement of radioactive source; more precise"
797
Lots of HNPCC what are the most common MMR defects?
MLH1/MSH2 (this one); PMS2, MSH6
798
What to do if MLH1 expression absent/low in tumor sample?
Test for MLH1 methylation
799
LMS staging - IB is what size cut off
5cm
800
Liver and renal clearance: one question each asking which agent is not dose adjusted
BICC THEM, MTV3D (2 questions)
801
Least emetogenecity
Vinca (THIS ONE), carbo, doxo, dactino
802
Least bone marrow suprresive
Bleomycin (main dose-limiting side effect is pulm tox, 10%; nephrotoxicity)
803
Least associated with germline mutation
p53, HER2 (this one- overamplification), APC (assoc with familiar adenomatous polyposis), MSH2
804
KRAS
associated with mucinous histology and with recurrent low grade serous carcinoma
805
IP chemo pharmacokinetics
"Generally - IP chemo should be LARGER, HYDROPHILIS, IONIZED - b/c clear more slowly from peritoneal cavity and cancer maintain concentration; penetrate tumor nodules through PASSIVE diffusion (up to 2-3 mm) but that's why we cytoreduce"
806
Integrin role in cancer
"metastases role (cell invasion and migration) adhesion of leukocytes to endothelial cells"
807
Inpatient treatment for neutropenic fever
"Need to cover Pseudomonas and other gram neg IV monotherapy ie., cefepime, imipenem or meropenem, cefepime, or zosyn Do not need vanco or aminoglycoside unless there is a clear clinical indication"
808
Infection assoc with spreading erythema, raised borders, lymphangitis
Nec fasc, gas gangrene, strep pyogenes - aka erysipelas (this one), staph (**Note: nec fasc almost never has lymphangitis)
809
"IMA collateral Which IS a collateral?"
"SMA and IMA communicate via marginal a. of Drummond (spleneic flexure and arc of Riolan aka meandering mesenteric artery is collateral that connectes the middle and left colic artery in the LUQ); but since absent/underdeveloped in 5% places splenic flexure at risk of ischemia IMA and internal iliac a. communicate via superior and middle/inferior rectal (hemorrhoidal) arteries (thus, rectum has dual blood supply from mesenteric and iliac arteries so more resistant to ischemia) Ext iliac, int iliac (this one), pancreaticoduodenal"
810
Hypocalcemia: know side effects - one of each asked
"PROLONGED QT (this one), hyperreflexia #1 = tetany; others- seizure, hypotension, prolonged QT, papilledema, psychological sx (less common confusion)"
811
Hypercalcemia sx
"SHORTENED QT (this one) mild Ca <12 asx or non-specific constipation, ftigue, depression moderate 12-14 polyuria, polydipsia (b/c can't concentrate urine), dehydration, anorexia, nausea, m. weakness, snesorium changes severe Ca >14 progression"
812
Hypercalcemia - which is first line for tx of acute hypercalcemia?
"Answer = Saline tx (mild) - hydrate with normal saline (NOT WATER), avoid thiazide diuretics tx (severe) - isotonic saline vol expansion, calcitonin, zoledronic acid; if refractory, can try denosumab"
813
How to tx DVT if renal failure
Don't use lovenox --> can use coumadin or argatroban or heparin or apixiban
814
How to control for confounding
Multivariate logistic regression
815
How to check impact of independent variable
Logistic regression
816
How do kinases work
Phosphorylation **Via INTRACELLULAR DOMAIN, not extracellular or transmembrane**
817
HNPCC not cancer - long list
"NOT breast // HNPCC is assocated with incr risk of endometrial, colon, gastric, ovarian, pancreatic, uretehral, brain (glioblastoma), small intestinal, sebaceous gland adenomatous polyps, keratoacanthomas"
818
"HIT II pt - next best step vs HIT I where plt ~100K, not immune-mediated, and can continue heparin"
"argatroban=direct thrombin inhibitor (THIS ONE- and ok in renal failure), heparin, warfarin can also consider fondaparinux=inhibits anti-Xa activity through antithrombin III, synthetic or if liver failure, use bivalirudin (also a direct thrombin inhibitor) occurs in 5% of pt exposed to heparin, anti-PF4 (platelet factor 4) thrombocytopenia = plt <150K plt drop usu >50% baseline, occurs 5-10d after exposure (could be earlier if recently exposed to heparin) THROMBOSIS (50% those with HIT, venous > arterial, can lead to skin necrosis, limb gangrene, organ infarction) resolution after stopping heparin is usually 7d"
819
Grade 3, IB endometrioid ovarian cancer
observation, 3 cycles chemo (THIS ONE based on GOG157), 6 cycles chemo
820
Formula for odds ratio (OR) vs. relative risk (and when to use each)
"(a/b) / (c/d) or (a*d)/(b*c) i.e., gave numerator (exposed case/unexp case) and you give denominator (exp control/unexp control) see 4x4 table on next page RR = a/(a+b) / c/(c+d) Use OR for case control (b/c compares presence/absence of exposure knowing the outcome) Use RR for cohort study (know exposure status, then calculate probability of event)"
821
Best test to eval association in case control trial
Odds ratio
822
Estrogen isoforms created by
Alterantive splicing (THIS ONE), amplification, 2 other choices
823
Endometrioisis/Clear cell carcinoma related marker
ARID1A
824
Endometrial cancer mutation associated with good prognosis
Excellent prognosis regardless of grade = POLE (question basically asked which scenario was most assoc with a POLE mutated EMCA: choices included low grade tumor, LVSI, low mutation rate, and others…)
825
Earliest lab value to measure in nutrition progress
Prealbumin (THIS ONE), albumin, 2 other choices
826
Doxil versus doxorubicin
"Liposomal bound (aka pegylated) witih MPEG methoxypolyethylene glycol to avoid detection by the mononuclear phagocyte system Doxil: longer plasma life, reduced volume of distribution, NOT a vesicant and associated with minimal cardiotox, alopecia, nausea/vomiting But increased rates of PPE (dose limiting in 25%) and stomatitis My answer choices were: increased clearance, decreased PPE, increased cardiotox, and decr effectiveness in EMCA tx (I chose this one)"
827
Doing an inguinal LND and injury nerve lateral/near the psoas, what will pt not be able to do
Addut thigh, extend knee/lift leg off bed (this one b/c of femoral nerve injury), abduct thigh, dorsi or plantar flex foot
828
Deficits from genitofemoral nerve injury
Sensory only; ipsilateral mons and labia majora; sensory of upper anterior thigh
829
Cytokine pro-inflammatory in sepsis
TNF-alpha (this one), IL-2 - note: IL-1 may have some role but TNF-alpha is stronger
830
Criteria for trachelectomy
"1. Desire to preserve fertility 2. Reproductive age 3. Squamous or adeno (i.e., not neuroendocrine) 4. Stage IA1 with LVSI, IA2, or IB1 5. Lesion
831
Contraindication to radical trachelectomy
LVSI, size 3 cm (this one), adenocarcinoma, multip
832
Cowden most common gyn cancer
Endometrial cancer (lifetime risk 19-28%)
833
Cowden most common cancer
Breast
834
What are advanced colon adenomas that increase colon cancer risk
Risk factors: villous or tubulovillous histology, high-grade dysplasia, >/= 1 cm
835
Cancer MOST at risk for with Li-Fraumeni
p53 mut - sarcoma (15% by age 70 in women), breast (54%), brain (6%), osteosarcoma (5%)
836
BRCA1 most common type of breast cancer
"Triple negative, IDC True… but these were NOT choices :( My answer choices were: basal-like, HER2 positive, Luminal A, Luminal B"
837
Branches of the internal iliac
"Posterior: ILS (iliolumbar, lateral sacral, superior gluteal) Anterior: Oranges under some ice might peel Obturator, uterine + umbilical, sup ves, inf ves, middle rectal, (int) pudendal, inf gluteal"
838
Best initial test to start with to evaluate smoking and certain type of cancer
Prospective RCT, case control (good initial study), cohort study, chart review
839
Base of the femoral triangle
Pectineous*, iliopsoas, adductor longus; roof - fascia lata; superior- inguinal ligament; lateral - sartorius; medial - adductor longus
840
AMG386 (Trebananib) - What does this target?
"AMG386 aka trebananib= angiopoietin (Ang) 1 and 2 neutralizing peptibody placental growth factor, hypoxia alpha something, VEGF, Tie1, angiopoieten 1/2"
841
AI most common side effect
Arthralgias (15-20%), HA (9-15%)
842
Afib in setting of heart failure in postop pt, how to treat acutely
"Metop (this one if they are stable; multiple RCTs show decreased mortality with BB; **Initial tx should utilize rate control and diuretics), verapamil, diltiazem (ca ch blockers have negative inotropic), cardioversion (only if unstable; ideal to perform echo prior to cardioversion if able) --> Amiodarone or dogoxin can be used if diminished ejection fraction NOT adenosine"
843
Abdominal compartment syndrome
"Measurement of bladder pressure (not imaging!) Conservative mgmt: avoiding positive fluid balance after initial resuscitation, evac intraluminal contents, evac space-occupying lesions (i.e., ascites, hematoma), improve abdominal wall compliance, decrease tidal volume/paralyze Surgical mgmt: abdominal decompression if pressure >25 mmHg (possibly 15-25 mmHg) with temporary wall closure"
844
% breast cancer risk reduction with oophorectomy in BRCA pos women
0.5
845
know electrolytes abnormalities and ECG changes **At least 3 questions**
"Hypercalcemia – shortened QT, Hypocalcemia – lengthened QT; Hypokalemia – flattened or inverted T waves, ST depression, U waves; Hyperkalemia – peaked T waves, ST depression; Hypomagnesemia – inreased PR and QT, torsades, atrial/vent arrhythmias; Hypermag – increased PR, QRS (level >13), increased QT"
846
What test to use to compare mean among three groups
ANOVA
847
Most common mutation in mucinous ovarian cancer (p53, KRAS, BRAF, Her2/neu)
KRAS
848
What vessel is most commonly encountered in femoral triangle
deep external pudendal (femoral artery)
849
What effect does ionizing radiation have on DNA that results in largest impact (double strand break, single strand break, base alteration, one other choice)
DS BREAK
850
What is the best timing of vaccination after spelenctomy
2 weeks preop (choices: 1 day, 10 days, 2-4 weeks (this one), 6 weeks)
851
What is most diagnostic of ARDS
"bilateral pulm infiltrates, Pa/FiO2 ratio<200 (this one), two more choices Berlin diagnostic criteria: 1. respiratory symptoms started wtihin 1 week 2. Bilateral opacities on CXR or CT (not explained by lung collapse, nodules, effusions) 3. Respiratory failure not explained by cardiac failure or fluid overload 4. PaO2/FiO2 <300 mmHg with PEEP > 5 (Mild = 200-300mmHg, moderate 100-200mmHg, severe < 100mmHg)"
852
PPV is dependent on
Prevalence
853
What is the difference between cardiogenic and hypovolemic shock (PCWP = LA pressure)
cardiogenic (high PCWP), hypovolemic (low PCWP). PCWP better than BP, CO, and UOP
854
Which chemo requires adjustment for renal compromise
Bleomycin, Cisplatin, Carbo, Etoposide, Topotecan, MTX, Ifos, Mitomycin, Hydroxyurea, Melphalan, VP-16
855
Which chemo requires adjustment for liver compromise
MTV3DV – methotrexate, taxotere, vincristine, vinblastine, VP-16, doxorubicin, cytoxan
856
PARP inhibitors (multiple questions)
**Need to know how side effect profiles differ between olaparib, rucaparib, niraparib, and _______)
857
What is the best adjuvant treatment for a pt s/p rad hyst with positive lymph node?
Pelvic RT + chemo (cisplatin preferred) (Peters criteria, GOG 109: +LN, +margin, +parametria got Cis 70mg/m2 and 5-FU q3wk x 4 cycles)
858
What nerve injury is associated with numbness over the thigh after a pelvic LND?
genfem
859
longest half life radio isotopes:
Cesium
860
Most common side effect of neurontin
dizziness
861
Superior border EBRT
L4-5 interspace - this one, L4 verterbral body, L5 vertebral body
862
What's the mechanism of action for Topotecan
Traps topoisomerase I on DNA causing unrepaired ssDNA break
863
PD-1 limits what? **Two nearly identical questions**
T-cell ACTIVATION
864
Which needs renal dosing more (etoposide vs. bleo) - since both are renally cleared
Bleo
865
Pre-renal findings
urine osm high (this one) - not urine NA high, urine/plasma cr, urine/plasma BUN
866
Old lady, ppx lovenox after surgeyr, CrCl 40 - what do you do for dosing. Same, 50%, other choices
Standard dosing (not recommended for CrCl <30, though can give for CrCl 20-29 at 30mg lovenox/day)
867
Phase III for platinum resistant recurrent ovarian cancer
cytoxan/avastin, taxol/avastin (this one)
868
Epithelial to mesenchymal transition
WNT/Beta-catenin
869
What is ipilimuab?
Monoclonal ab for CTL-4 - for melanoma
870
Adverse effects from massive transfusion
HYPOcalcemia and alkalosis due to citrate tox
871
What phase of the cell cycle is most radio-resistant?
Mid to late S and early G1 (Answer = S)
872
Base of the femoral triangle
Pectineous*, iliopsoas, adductor longus; roof - fascia lata; superior- inguinal ligament; lateral - sartorius; medial - adductor longus
873
ATN
"FeNa >2%, will have normal BUN:Cr ratio (10 or 15:1), UA with hyaline or grnaular casts or epithelial cell casts Loss of urine concentrating ability to low urine osm (as opposed to pre-renal where concentrating the urine so high urine osm)"
874
at what age do you start HNPCC testing
20 (THIS ONE), 30, immediately
875
Associated with decreased SSI with rectosigmoid resection
Chlorhexadine bath, normotheramia, mechanical and antibiotic prep (this one)
876
Ascites and ovarian cancer - which VEGF
VEGFR2 by VEGF-A has major permeability enhancing effect
877
Artery in inguinal triangle
Inferior epigastric a
878
Appearance of radiation enteritis on imaging
Diffuse bowel wall thickening
879
Another cause of anastomotic leak
Increasing ascites >4L, alb <2 (this one?), smoking
880
Ang-1, Ang-2 targets
"hypoxia-alpha something, TIE 1 (THIS ONE), FGF angiopoietin-Tie pathway is a vascular-specific receptor tyrosine kinase pathway essential for normal vasc development"
881
AMG386 - target
"AMG386 aka trebananib= angiopoietin (Ang) 1 and 2 neutralizing peptibody placental growth factor, hypoxia alpha something, VEGF, Tie1, angiopoieten 1/2"
882
Alternative statistical methods to maintain power?
"Non-parametric (does not assume anything about the distribution; good for outliers, skewed distribution, small sample size)"
883
AI most common side
Arthralgias (15-20%), HA (9-15%)
884
AGC-NOS during pregnancy, colpo neg at 22 weeks
repap postpartum
885
Afib in setting of heart failure in postop pt, how to treat acutely
"Metop (this one if they are stable; multiple RCTs show decreased mortality with BB), verapamil, diltiazem (ca ch blockers have negative inotropic), cardioversion (if unstable) --> based on uptodate amio or dogoxin maybe not choices NOT adenosine"
886
Advantage of HDR vs LDR
Less tx time (this one), less tx, less tox, more effective -- HDR has higher tox, may lose radiobiologic advantage of LDR, tx faster
887
Abx that don't require renal dosing
Ceftriaxone, clinda, second gen PCN (oxacillin, nafcillin), cefoxitin, doxy, erythro, flagyl, linezolid
888
Abdominal compartment syndrome
"Measurement of bladder pressure (not imaging!) Conservative mgmt: avoiding positive fluid balance after initial resuscitation, evac intraluminal contents, evac space-occupying lesions (i.e., ascites, hematoma), improve abdominal wall compliance, decrease tidal volume/paralyze Surgical mgmt: abdominal decompression if pressure >25 mmHg (possibly 15-25 mmHg) with temporary wall closure"
889
8 cm defect between vulva and anus - best flap?
Gracilis (this one), VRAM, rhomboid, 2 others
890
41 yo with choriocarcinoma 7 months from pregnancy with pulm mets too numerous to count - what to treat
"multiagent (based on WHO score) - EMACO AGE >/=40 Antecedent Abortion, term pregnancy 4-6 months interpregnancy interval, 7-12 months HCG 1k-10k, 10k-100k largest tumor 3-4cm, >/=5cm mets in spleen/kidney, GI total mets 1-4, 5-8 Previous failed single drug = 2"
891
32 weeks pregnant, 7 cm cystic adnexal mass - what do you do?
US after delivery or Vaginal delivery with operation if mass persists
892
300 dyne and increased CO - what type of shock?
"Sepsis Distributive shock- low SVR (<900 dynes per second/cm^5) and normal or high CO Cardiogenic shock- high SVR (>1400 dynes/second/cm^5) and low CO ; high PCWP geater than 15 mmHg (right atrial pressure)"
893
3 ways that oncogenes are activiated, which is not
mutation in prmoter region regulating inactivation, amplification, hypermethalation (this one), chromosome rearrangement
894
20 years after chemoRT, which risk factor led to lumbosacral radiculopathy
cisplatin, increased dose per fraction (THIS ONE, lumbosacral radiculopathy is assocaited wit hintracavitary and intraop radiation), 5FU cream
895
18 weeks pregnant, s/p CKC for AIS with positive margins and ECC, what to do
Observe
896
14 weeks with ASCUS HPV, no gross lesions, what do you do
colpo immediately (THIS ONE), colpo at 20 weeks, cone, repeat pap
897
12 weeks pregnant, endodermal sinus tumor
Tx with chemo BEP
898
% breast cancer risk reduction with oophorectomy in BRCA pos women
0.5
899
"**Which of the following is associated with steatosis aka fatty liver in TPN? 1. excess calories from glucose 2. excess calories from protein 3. excess calories from fat 4. excess calories from any source 5. insufficient fat soluble vitamins; 6. insufficient calories from fat"
excess calories from glucose/dextrose (aka overfeeding syndrome)
900
RR of raloxifene and thrombosis
RR 2.1 (grady 2004, RCT of 7700+ women)
901
know vulvar staging
"IA Tumor confined to the vulva or perineum, ≤ 2cm in size with stromal invasion ≤ 1mm, negative nodes IB Tumor confined to the vulva or perineum, > 2cm in size or with stromal invasion > 1mm, negative nodes II Tumor of any size with adjacent spread (1/3 lower urethra, 1/3 lower vagina, anus), negative nodes IIIA Tumor of any size with positive inguino-femoral lymph nodes (i) 1 lymph node metastasis greater than or equal to 5 mm (ii) 1-2 lymph node metastasis(es) of less than 5 mm IIIB (i) 2 or more lymph nodes metastases greater than or equal to 5 mm (ii) 3 or more lymph nodes metastases less than 5 mm IIIC Positive node(s) with extracapsular spread IVA (i) Tumor invades other regional structures (2/3 upper urethra, 2/3 upper vagina), bladder mucosa, rectal mucosa, or fixed to pelvic bone (ii) Fixed or ulcerated inguino-femoral lymph nodes IVB Any distant metastasis including pelvic lymph nodes"
902
What is best adjuvant treatment for woman referred to you s/p TAH/BSO with diagnosis of leiomyosarcoma (WPRT, gem/taxotere, brachy, staging procedure)
gem/tax
903
Best adj tx for uLMS diagnosed post-hyst
WPRT, gem/tax (THIS ONE), brachy, staging (not for LMS
904
What is function of gemzar prodrug
substitutes cytosine that stops replication by "masked chain termination"
905
What is least leukomegenic chemo
bleo
906
What are the axes on ROC
x- 1-spec, y- sens, better if sharp upper left corner
907
What is best way to diagnose HNPCC
genetic testing for MLH1/MSH2
908
What is best treatment for first relapse c. diff (IV flagyl, IV vanc, PO flagyl, some other choice)
"po flagyl If previous PO vanc: pulse-tapered PO vanc, PO fidaxomicin If previous fidaxomicin or flagyl: PO vanc"
909
What preop abx is most associated with c. diff development (cefotetan, ertapenem, two other choices)
cefotetan (clinda or cephalosporins)
910
What has the most collateral circulation with the IMA (the external iliac, internal iliac, inferior pancreaticoduodenal, another choice)
INTERNAL ILIAC
911
know electrolytes abnormalities and ECG changes
"Hypercalcemia – shortened QT, Hypocalcemia – lengthened QT; Hypokalemia – flattened or inverted T waves, ST depression, U waves; Hyperkalemia – peaked T waves, ST depression; Hypomagnesemia – inreased PR and QT, torsades, atrial/vent arrhythmias; Hypermag – increased PR, QRS (level >13), increased QT"
912
What do you do intraop if recognized pancreatic injury during ovarian cancer debulk (repair injury, pancreatectomy, splenectomy, place pelvic drain)
drain
913
What test to use to compare mean among three groups
ANOVA
914
Most common mutation in mucinous ovarian cancer (p53, KRAS, BRAF, Her2/neu)
KRAS
915
Advantage of HDR over LDR
less exposure of staff to radiation for prolonged periods of time (THIS ONE), other options included less treatments, less toxicity
916
What is biggest barrier to ovarian cancer screening
(I chose low specificity of existing tests) prevalence
917
Treat hypermagnesemia with slow infusion of one of the following (Lasix, calcium, other choices)
calcium gluconate (reverse neuromuscular and cardiac effects of magnesium)
918
Patient with partial mole is most consistent with
no embryo, diploid, likely persistence after evacuation, one other choice
919
What vessel is most commonly encountered in femoral triangle
deep external pudendal (femoral artery)
920
What effect does ionizing radiation have on DNA that results in largest impact (double strand break, single strand break, base alteration, one other choice)
DS BREAK
921
What is the best timing of vaccination before spelenctomy
2 weeks preop
922
What is least important vaccination to given in setting of splenectomy?
need meningococcal, H. flu, strep pneu, answer was fourth option
923
What is most diagnostic of ARDS
"bilateral pulm infiltrates, Pa/FiO2 ratio<200 (this one), two more choices Berlin diagnostic criteria: 1. respiratory symptoms started wtihin 1 week 2. Bilateral opacities on CXR or CT (not explained by lung collapse, nodules, effusions) 3. Respiratory failure not explained by cardiac failure or fluid overload 4. PaO2/FiO2 <300 mmHg with PEEP > 5 (Mild = 200-300mmHg, moderate 100-200mmHg, severe < 100mmHg)"
924
Topo vs etoposide (what is actual function of topo, does etopo bind topo I or II)
topo – topo I, etop – topo II
925
PPV is dependent on
Prevalence
926
What is the difference between cardiogenic and hypovolemic shock (PCWP = LA pressure)
cardiogenic (high PCWP), hypovolemic (low PCWP). PCWP better than BP, CO, and UOP
927
MANY questions regarding urine electrolytes – differentiate between ATN and prerenal causes (FENa, urine/plasma Na, urine/plasma creatinine, BUN/creatinine ratio, urine osmolality or osmolarity, Urine Na. parameters: Urine Na >40, urine osmolality >500, bun/cr <20. Most gave broad parameters, one with specific parameters
928
What distinguishes invasive from noninvasive ovarian disease
BRAF expression in LMP
929
Which chemo requires adjustment for renal compromise
Bleomycin, Cisplatin, Carbo, Etoposide, Topotecan, MTX, Ifos, Mitomycin, Hydroxyurea, Melphalan, VP-16
930
Which chemo requires adjustment for liver compromise
MTV3DV – methotrexate, taxotere, vincristine, vinblastine, VP-16, doxorubicin, cytoxan
931
Mechanism of PARP inhibitors (multiple questions)
932
Which was most likely to have ureteral obstruction: RT then extrafascial hyst, rad hyst then RT, different types of RT
rad hyst then RT
933
Distal obstruction due to malignant disease with Cecum 12 cm: Transcutaneous gastrostomy, Percutaneous cecostomy, Transverse colostomy, stent
transverse colostomy
934
Targets of Gleevec (Imatinib)
ckit, ABL, PDGFR are direct targets. Ras/MAPK, Src/Pax/Rak/Rac, PI/PI3K/AKT/BCL2, and JAK/STAT are downstream
935
MOA P53 as tumor suppressor
can activate DNA repair, cause G1/S arrest to allow time for repair of DNA damage, maintains genomic stability, initiate apoptosis
936
What is the best adjuvant treatment for a pt s/p rad hyst with positive parametrial?
Pelvic RT +chemo (Peters criteria: +LN, +margin, +parametria got Cis 70mg/m2 and 5-FU q3wk x 4 cycles)
937
Woman who is 12 months s/p rad hyst with unilateral leg swelling no erythema what is the best test to order to diagnose
LE DOPPLER
938
Does 3 hr vs 24 hr administration of taxol lead to increase neurotoxicity or decrease in neurotoxicity?
3 hour more neurotoxic, 24 hour more neutropenia
939
Lots of questions regarding are prodrugs
940
What vessels are encountered in the femoral triangle
superficial external pudendal, superficial inferior epigastric, superficial circumflex iliac artery
941
What nerve injury is associated with numbness over the thigh after a pelvic LND?
genfem
942
Which is NOT a branch of the femoral artery?
Deep circumflex iliac – off external iliac
943
What has been associated with decreased infection in groin dissection?
Saphenous vein sparing
944
longest half life radio isotopes:
Cesium
945
Most common side effect of neurontin
dizziness
946
Adenoma malignum syndrome association
Peutz Jaghers
947
Her2- ERB2!!!!!
948
Superior border EBRT
L4-5 interspace - this one, L4 verterbral body, L5 vertebral body
949
Bev
activates MAPK/ERK
950
Nausea vomiting affected by
uremia, hyperCa, meds - chemoreceptors of brain
951
Most common serious side effect of tamox
thrombosis, ut cancer, vasomotor (THIS ONE), colon cancer
952
What's the mechanism of action for Topotecan
Traps topoisomerase I on DNA causing unrepaired ssDNA break
953
Mutation associated with mucinous epithelial ovarian cancer
KRAS, tp53
954
Mucinous most common tumor suppressor
tp53
955
What's the half life of Cesium?
30 years
956
PD-1 limits T cell ?activation
957
Pertuzumab
Block HER2 heterodimerization
958
Fascial plane in inferior dissection of radical vulvectomy
Colle's fascia, inferior and superior fascia of the urogenital diaphragm
959
Which flap lowest failure - gracilis, TRAM, other things I've never heard of
960
What would need a larger sample size - log transformation, non-parametric, OR with CI rather than just p-value (this one)
961
Which needs renal dosing more (etoposide vs. bleo) - since both are renally cleared
Bleo
962
Pre-renal (urine osm high this one - not urine NA high, urine/plasma cr, urine/plasma BUN)
963
Old lady, ppx lovenox after surgeyr, CrCl <40 - what do you do for dosing. Same, 50%, other choices
Same dosing
964
Phase III for platinum resistant recurrent ovarian cancer - cytoxan/avastin, taxol/avastin (this one)
965
Epithelial to mesenchymal transition - WNT/Beta-catenin
966
Translocation associated with cancer - STK11- sex cord stromal of ovary (this one), gastric
967
What is quality assurance?
968
Telomerase
"Telomeres are at ""caps"" at ends of chromosomes and keep chromosomes from being degrade Every time cell divides, a few base pairs lost and eventually these ""caps"" are gone Telomerase is a protein/DNA complex that lengthens the 3' telomere end so the cell can divide forever (and thus be immortalized)"
969
IL-2 stimulates which cells?
Cytotoxic (Tc) and helper (Th) cells
970
MHC and CD4 - which go with which?
"Tc = MHC1 = CD8 = apoptosis (C looks like pacman eating, MCH1 and CD8) Th = MHC2 = CD4"
971
Where are B cells made
Produced in bone marrow then migrate to spleen, LN, GI tract to mature
972
Most radiosensitive?
G2 and M (M is best answer, but wasn't answer choice… G2 was)
973
What organ is most sensitive to radiation?
Kidney
974
Most common p53 mutation?
Missense (one base pair that alters function) - celll compensates by trying to make more So would have increase in detectable p53 Compared to nonsense mutation where the protein is not made, so absence of p53
975
What is the half life of albumin
20 days / 3w
976
Hyponatremia correction rate to avoid what complication
9 meQ/L/24h to avoid central pontine myelinolysis (osmotic demyelination)
977
"What supplies the sartorious muscle? And tensor fascia lata"
LATERAL femoral circumflex (versus medial femoral circumflex for the gracilis)
978
nerve most likely to be injured with sartorius transposition
lateral femoral cutaneous, and others
979
Which chemo is activated within a tumor cell?
Xeloda (aka Capcitabine)
980
Most common side effect of whole pelvic XRT
ileum (this one), rectum, bladder, ureter
981
what opiate causes prolonged QT and torsades
methadone
982
what happens with trendelenburg and pneumoperitoneum
increase in CVP, PCRP, SVR, MAP and decrease in CO
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